NC0082716_ORC Designation Form_20220201

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 9G .0201
rAR to Navigate Form
Facility Name: WOLF LAUREL WWTP Permit# NCO082716
FacilityType: WW Facility Grade: 11 SUOM1rASEPARATpfpAMFOR6ACHCtASStF(CATION
Permittes Owner/Officer Name: ORVILLE ENGLISH
Email Address:
Permlttee Signature:
Fun ivame: UvTT1\� 1 ► r-� v r-'-N Work Phone: [phone]
Email Address: OFFICE@JJEMLNET
r
Date: 2 1 _12�
Certificate Type: WW Certificate Grade: I ERi 1
---- Certificate #: 2- 03
Signature: Effective Date:
of th t l agree to my designati' as th perator in Responsible Charge for the facility noted. l understand and will
abide by e rules and regulations p aining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and
failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name: 5���0(� �M Work Phone: [phone]
Certificate Type: WW Certificate Grade: ,I _._ Certificate #:
Signature: -- r
Effective Date: I-77
"l certify that !agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name: (�/�� M ` Work Phone: [phone]
Certificate Type: WW Certificate Gra ; I +
%� Certificate #: 4� (' 3� b
Signature:
"I certify that I ag
abide by the rules
so can result in Dii
mu� 6�4 Effective Date: 7' Z�
to my designation as a B ck-up Operator in Responsible Charge for the facility noted. I understand and will
regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do
inory Actions by the Water Pollution Control System Operators Certification rnmmil ;n.,
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: 919- 71 6 Icertadmin@ncde
Mail or fax a COPY to: Asheville-2090 US Hwy 70, Asheville, NC 28778 I FAX: [phone] PH: 8 _~ —�
-- I 2.-.'6W500, :D 2 ', INTi
Water Quality Region a,
Operations
Asheville Regional Office

Facility Name: WOLF LAUREL WWTP Permit #
NCO082716
Page 2
Full Name: Davis James Work Phone: [phone]
Certificate Type: WW Certificate Grade: II Certificate #: 997463
Signature: qiw� Effective Date: /�_' I .- '��
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in ISA NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that/ agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."