WQ0018708_Operator Designation_20160729

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Lake Creek Corporation) Steve Jones
Faciiiitq Name:
Mailing Address: 33 West Bay Ridge Road
City: Harretls
Email Address: [e-mail]
Signature:
Baytree Lakes
County: Nader
State: NC
Phone: [phone]
Zip: 28444
Date:
Permit # WQ0018708
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Facility Grade:
SI
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Narne: Tony Baldwin
Certificate Type: SI
Email Address:
Certificate Grade: Select
[e-mail]
Wok Phone: [phone]
Cerificate ft: 29101
Signature: �, ; , ; .G c Date: E -- �r / % Li.'
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility •oted. i understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 0I-3 .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certlficatlon Commission.
BACKUP ORC
Print Full Name: Anthony Branch
Certificate Type: Si
Email Address:7
Certificate Grade: Select
branch@envi rolin kinc. com
v; ork Phone: [phone]
Cartificate it 990486
Signature: .,,SjJt,va„_! ,"-Lt."-. Date: --.-1 ..,'�- ( b
'7 certify that I agree to my designation asrJ Back-up Operator in Responsible Charge for the fc:ility noted. I understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC ?8G .C°204 and failing to do so con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.
Mail, fax or email
ORIGINAL to:
Mall or Fax
a COPY to:
WPCSOCC, 1618 Mail Service Center,
Raleigh, NC 27699-1618
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Email: [e-mail]
Mooresviile
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: 704-:,63-6040
Phone: 7!:4-661:-1699
Winston-.ialein
45 W. Hales Mall Rd.
Winston-ialern, NC 27105
Fax: [phone]
Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone: [phone]
Ruvised 4/2016