NC0036269_Operator Designation_20220505

RfetrifitigeffelibN CONTROL SYSTEM OPERATOR DESIGNATION FORM
MAY - 5 2022
NCAC 15A 8G .0201
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MOORESVILLE RE3IONAL OFFICEI
Facility Name: Rocky RRegional egiona Wastewater Treatment Plant Permit # NC0036269
Facility Type: WW a
Facility Grade: IV SUBMITA SEPARATE FORM FOR EACH CLASS1FICA TION
Permittee Owner/Officer Name: Travis Mark Fowler
Email Address:
[e-mail]
Permittee Signature:
m
Full Name: James Christian Sims
Email Address.
ORC
Operator in Responsible Charge
[e-mail]
Certificate Type• WW El
Signature:
Full Name:
Date:
2e,
Work Phone: [phone]
Certificate Grade: IV LJ Certificate #: 999309
Effective Date: 572. /2 2-
"I cer y that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will
obi e by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and
failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Karen Renee Marie
Certificate Type: WW ®'1
Signature:
Full Name:
Certificate Grade: IV
Work Phone: [phone]
Certificate #: 1002612
Effective Date: 9 Z!- ZZ
"I 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 ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Braden Joshua Cook
Certificate Type: WW 0 Certificate Grade: IV
Signature:
( `Ts co
gifigial
Work Phone: [phone]
Certificate #: 1002815
Effective Date: hi . .
"1 certiYy t : 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 ORC as set forth in 15A NCAC 08G .0204 and failing to do
so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 I FAX: [phone] I certadmin@ncdenr gov
Mail or fax a COPY to: j Mooresville-610 E. Center Ave., Suite 301, Mooresville, NC 28115 I FAX: [phone] I PH: 704-663-1699 L
Revised 3/2019

Page 2
Facility Name: Rocky River Regional Wastewater Treatment Plant Permit #: NC0036269
Full Name:
Backup ORC
Nicholas James Merwin
Certificate Type: WW
Signature:
Certificate Grade: IV
Work Phone: [phone]
Certificate #: 1006823
Effective Date: 4- Z. 5- ZG L Z
"/ certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / 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 failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Kevin Morgan Graves
Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 999374
Signature:
Effective Date: LI.2 5 • ZaZ'_
"l ce ify that I agre 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 ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Jesse Lee Wingler
Certificate Type: WW LJ Certificate Grade: IV
Signature:
Work Phone: [phone]
Certificate #: 1004838
Effective Date: '1L PS -02
certify that l agree tm designation ignation 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 ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
6
Backup ORC
Full Name: Oriss Wayne Cross
Certificate Type: WW Certificate Grade: IV
Signature:
Work Phone: [phone]
Certificate #: 1010733
Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / 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 failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."

Page 2
Facility Name: Rocky River Regional Wastewater Treatment Plant Permit #: NC0036269
Full Name:
Backup ORC
Nathaniel Ryan Hargrove
Certificate Type: WW EJ Certificate Grade: IV
Signature:
Work Phone: [phone]
Certificate #: 1002601
Effective Date: `l- 2?- 2.Z
"/ certify that I 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 ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Adam Neal Love Work Phone: [phone]
Certificate Type: WW LI Certificate Grade: IV Certificate #: 1009200
Signature:
Full Name:
id4
Effective Date:2-
"1 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / 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 failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Certificate Type: Select LJ Certificate Grade: Select D
Signature:
Work Phone:
Certificate #:
Effective Date:
"/ certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / 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 failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Work Phone:
Certificate Type: Select EJ Certificate Grade: Select a Certificate #:
Signature: Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC O8G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."