NC0086606_Operator Designator Form_20220324

Water Pollution Control System Operator Designation Fog/
WPCSOCC
NCAC 15A SG .0281
Carolina Water Service of NC
Permittee Owner/Officer Name:
Mailing Address: 4944 Parkway Plaza Blvd, suite 375
City: Charlotte State: NC Zip: 2217
Phone #: (704 } 525_7o90
Emil address: roay.konsutrolinawaterservieene.cona
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SignatUre: Tony ons. rtraza ek.d7A.4,ue tac
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Facility Name: The Harbour Well 4
Date:
EIVED/NCDEO/DVVR
MAR 2 4 2022
WQROS
MOORESVILLE REGIONAL OFFICE
Permit #: NC0086606
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM
Facility Tyne/Grade:
Biological WWTP Surface Irrigation
PhysicaliCheinical 1 Land Application
Collection System
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Operator in Responsible Charge (ORC)
Print Full Name: Mark R. Haver
Certificate Type Grade / Number: PC 1 994053 Work Phone [phone]
Siumture:
Date:
-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 0&i .0204 and failing to do so can result in Diselplinaty
Actions by the Water Pollution Control System Operators Certification Commission. -
Back -Up Operator in Responsible Charge (BU ORC)
Tony Konsul
Print Full Name:
Certificate Type / Grade / Nutnber: PC - 1- 985369 Work Phone #: ( 704 576-1685
Signature: Tony Konsu
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Date:
"F certify that 1 agree to mv desienation as a Back. -up Operator in Revonsibie Charec for the facility noted_ F uriderstand and Mil abide by the
tides and regulations penainine to the responsibilities of the BO ORC as set forth in t 5A NCAC 08G .0205 and filing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mak fitx or entail the
original to: tee
Hail or fax- a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Maii Service Center, Raleigh, NC 27699-1618 Fax [phone]
Asheville
2090 US Hwy 70
Su:311=mo 28778
Fax: [phone]
Phone: [phone]E10
Washington
943 Washington_ Sci !vial!
Washington 27889
FtlY1 251946.9115
Phone: [phone]M
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: 9E0.4313300
Wilmington,
127 Cardinal Dr
Wilmington 28405-2845
Faxt- 910.3501018
Plume: 910.796.7215
Mooresville
610 E Center Ave
Suite 30
Mooresville 281 15
Fa: 704.663.61140
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston-Saletn 27107
Fay: 336.771.4631
Plume: 336.771.5000
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: 919571_471a
Phone:[phone]
Revised 02-2013