WQ0000948_Backup ORC Designation Form_20220429

Town of Jackson
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P. O. Box 614
Jackson, N. C. 27845
Phone: [phone] Fax: [phone]

-WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: pile Mgj5S0fJ / j-44146R.—TABS M, VL. x
Mailing Address: }7p P6&, 1& _ Phone: c4.
Clty: 7 r4.0 X g O A) State: _ �T zip: z7 q
Email Address: 1 49Ie�,dea�
Signature: 1`"i Date. p+l.#,-2,� ,
s �.a��•
Facility Name: r�i � ' , FiC an) SPA+I- `r-RR•ICArior).f VM Permit It
County:
NC Dept of Environmental Qualir!
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: wW
Facility Grade:
APR
Raleigh Regional Office
OPERATOR IN RESPONSIBLE CHARGE TORE)
Print Full Name- %AA)A) &&"L-> [,.- Work Phone: Z�SZ.-S314-38i1
Certificate Type;
Email Address:
Signature:
5Y
Certificate Grade: 1 Certificate #: Z 5 1 24
Effective Date:
"1 certify that 1 agree to my QRercfnatlon`as the bre'rator Responsible Charge for the facility noted. t 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 falling to do so can result in
Disciplinary Actions by to Water Pollution Control System Operators Certification Commiss;on."
BACKUP ORC _ — -
Print full Name: rCarl Lr\s Work Phone
Certificate Type; �.-.�...
yp .$� ertificate Grade:: I Certificate #:Sbrq �`,
Email Address: rt a . (. 03 7
Signature: Effective Date: k:0 j
"! certify that ! agree t my design tion as a Back-up Op rotor in Responsible Charge for the facility noted. r understand and will abide by
the rules and regulations pertaining to the responsibllltles of the ORC as set forth in 15A NCAC 08G .0204 and falling to do so can result in
05ciplinary Actions by the Water Pollution control5ystem Operators Certification Commission."
Mail, fax or email
WPCSOCC, 161E Mail Service Center, Fax: [phone] Email: [e-mail]
OR)GINAL to:
Raleigh, NC 27699-1618
Mail or Fax
Asheville
Fayetteville
Mooresville
Raleigh
a COPY to:
2090 US Hwy 70
225 Green St., Suite 714
610 E. Center Ave., Suite 301
3800 Barrett Or
Swannanoa, NC 28778
Fayetteville, NC 28301-5043
Mooresville, NC 28115
Rale"gh, NC 27609
Fax: [phone]
Fax: [phone]
Fax: [phone]
Fax.,919 571 4718
Phone: [phone]
Phone: [phone]
Phone: [phone]
Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Or. 45 W. Hanes Mall Rd,
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone: [phone] Phone, 910-796-771.5 Phones: R-AFi-77A ARnr1