NC0049620_ORC Designation Form_20220101

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
Facility Name:
NCAC 15A 8G .0201
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HOT SPRINGS HOUSING AUTHORITY WWTP
Permit # NCO049620
Facility Type: WW Facility Grade: I 5usmliA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: ABIGAIL NORTON
Email Address; [e-mail]
Certificate Type:.WW...... Certificate Grade: )
Signature
Certificate #: 1005990
Effective Date: 01/01/2022
"I certify that I agree to my designation as the 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."
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k ORC
Full Name: JUANITA JAMES Work Phone: [phone]
Certificate Type: WW _. Certificate Grade: .III.
Certificate #: 24074
Signature: Effective Date: 0110112022
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"I certify thou gree to my designa n as a Back-up Operator in Responsible Charge for the facility noted. I understand and will
abide by the uTes and re,Yrtations attaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in DiscipiinoryActions by the Water Pollution Control System Operators Certification Commission."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
'I certifythat i a ree to designation as a Back-up Operator in Responsible Charge or the facility noted I understand and will
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obide by the rules and regulations pertaining to the responsibilities of the ORC as set forthi in 15A NCAC 08G 0204 and foiling to do
so can result in Disciplinary Actions by the Water Pollution Control System Operators i tr i t 1mhi'" \
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 I FA 71S-2726 I certadmin@ncder r g
Mail or fax a COPY to: Asheville-2090 US Hwy 70, Asheville, NC 28778 I FAX: [phone] j 8 $-29ffi�0 I
Water Quality Regional OMom,,-�To»
Asheville Regional Office

Sip -nature: AW&OgNt
, A bigaYNowfon (Jan 1 1-1, 20,22. If,: 21 ES I
Email: [e-mail]