NC0062383_Operator Designator Form_20220324

Pernittee Chv ner/O
A dre s:
City:
Email ad dre
Pollution Control System perator De ignat
wpCSocC
NCAC (5A NG .0201
Paris-
CarohinaWater Service of NC
t ny. .onsu .'i a: tv c
m.MV, s ax a+.r .a a
Tony Konsul `�
geEIVED/NCDEQ/DWR
MAR 2 4 2022
WORS
MOORESVILLE REGIONAL OFFICE
Phone (704
Date:
Facility- Name: Queens Harbor Per it
SUBMIT A SEPARATE FORM FOR EACH'PE S`ST
Facilit - Type/Grade;
Biological WlVTP 1 Surface Irrigation
Physical'Che:nicll Laud Application
Collection System
Operator in Responsible ChargeMC)
Print Full Name:
Cc
Kenneth Knopf
NC OO62333
WW 2 - 994883
ficate Type Grade Number:
Kenneth Kn©p
-and reoul;
Aciions ios;' t I cctn€at
Rack -LAP Operator in Responsible Charge (` ORC)
Print Full Nw m: Mark. R. Haver
Certificate Tye , Grade Number
Signature:
y designamn as a Bar
.. x. fit, as3`.
/4,r9
Work Pht
L304 ) 3 1-437
Sate:
3/14/22
( 704, 36I-0
t...3 S x4.9;tkaa
rai
mail the 'PC CC, 1618 I;ail Service Center, Ratel C ' -t t Fax: 919AirL6492
appropriate Rcgi.n
21 g
'y; i nan a
882 299_7043
Phone: 2L 6.-15EIi)
Fayetteviiir
225
9E0,V4 ,0107
Ph€sisc: 910,1333300
iIuiT€[igott
\Fll
Lire 103$0
Phone: 91 J 796. 235
Fast:: its-Lt
Phone: a.€
WinctoII-Sale Eli
5 -_ W2uhu ;=n Si
ip`:lc 33(T 1_U31
Phone: 336,771.511(10
Rniek;(h
8 0 Ban -en Dr
r »aa.h
Fax:
Phon : 19.791. ua

Farilt
arbor
Bark -Cep Operator in Responsible Charge (BC-' OR;
Print Full game: Larry eery
,st certify that I agree
rules anti rsgu :nta{sr pe inin
D •iplittary Actions by the
Permit
NCO()2 8.
Back -Up Operator in Responsible Charge (BU ORC)
Pr i tName: Tommy Capps
?'W ,.r'' 2 995695
c p ns k 9a .,ge
rttl `;tt and re iatio '3'„- s .E t the r"'" @3a#ibilit t; of th a ORC as sItt faith in 3
Ditwipiinam Actions $ _ ar Po uts*�t3t control SN-stan Optaitors Ccrffii _ ti€ a Coratm
rk Pho
320_5 And f
a Ja. by, the
rc u1t d8�
Back -Up Operator in Responsible Charge (BU ORC)
Pant Full Name:
Ceriilicat ade umber:
rk Phcmc (
Date:
my deAgnattost 25 a ttktk-tt
£&n c''., at€ I am
Rcsporbittle Ckuyt' far a
Back -Up Operator in Re puresible Charge U ORC)
Print Full Nam
'10ft and
ii c �t ype Grade / cumber: Vork Phonc
tare:
Hai_sc rtii :ayy Actions
Date:
tom. itrlikrstztnti anti
Revised d 02-2013