NC0071242_Operator Designator Form_20220324

Water Po
utio
Mailing Address: 4944 Parkway Plaza Blvd, suite 375
City: Charlotte
Control System Operator Designation Form
HtUEIVED/NCDEQ/DWR
WPCSOCC
NCAC 15A 8G .0201
MAR ',1! 4 2022
WQAOS
Permittee Owner/Officer Name: Carolina Water Service of NC
MOORESVILLE REGIONAL OFFICE
State: NC Zip: 28217 Phone #: (704 ) 525-7990
Email address: tony.konsulAcarolinawaterservicenc.com
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Signature: Tony Konsui
Date:
Facility Naine: Rivetpointe
Permit #: NC007 1242
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tvne/Grade:
Biological WWTP it Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name: Kenneth Knopf
Certificate Type / Grade / Number: WW 2 - 994883Work Phone #: (704 ) 161-4377
---r......=..-=7-_--
Kenneth Knopf ,..,..,== Date: 3/14/22
Signature:
"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 IBA NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Mark R. Haver
Certificate Type / Grade I Number: WW 4 990823
Signature:
Work Phone #:
704) 36170645
Date:
"1 certify that 1 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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center,
certadminalnedenr.aoy
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Raleigh, NC 27699-1618
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: 910A33.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salein
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 02-2013

Faciiit Name: Rivcipointe
Permit #- NC0071242'
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Larry Henry
Certificate Type / Grader Number:
Signature:
-1 certify that I agree t esignation as a B
rules and regulations pertaining to the res
Disciplinary Actions by the Water Polluti
Work Phone #:. (704
Date: 3t 1'o
''ate
61-0641
Responsible Charge for the facility noted. I understand and will abide by the
e BU ORC as set forth in I5A NCAC 08G .0205 and failing to do so can result in
Operators Certification Commission. -
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Tommy Capps
Certificate Type / Grade / Number: { 2 495695 Work Phone #: (704 ) 361-5067
Signature:
Date: 3 /l o 2 - .
"I certify that I wee to my desi'gttation as a back-up Operator in Responsible Charge liar the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in I5A NCAC O8G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back: Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade i" Number: Work Phone
Signature: Date:
"l certify that l 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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: Date:
certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in l5A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 02-2013