NC0060755_Other Agency Documents_20220607

Water PoHution Co
City:
Email adt s: ' 7 `• &o
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al System Operator Designation Form___ _
WPCSOCC
NCAC ISA $G .1211
UBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP
Physical/Chemical
Collection System
Surface Irrigation
Land Application
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Operator in RcsponiThie Charge (ORC)
Print Fall Name: +c
Certificate Type / Grade / Number: k/ k/ / 2-7 I ° 16
Signature: i
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JUN 17 2022
WQROS
MOORESVILLE REGIONAL OFFICE
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Work Phan a #: S' i »7G 2 V
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"I certify that I agree to any dmignation es the Operator in itcq,unable Charge for the facility noted. I unders*mtd and will abide try the rules
and regulations pertaining to the responaibiiities of the ORC as set forth in 1 SA NCAC 08C .0204 and Ealing to do so can remit in Disciplinary
Actions by the Water Pollution Control System Op ors Certification f lrrmeiaaion "
Rk-Up Operator in Rssponsble Charge (BU ORC)
Print Full Name:
Certificate Type
Signatire: j
"I certify that I
Hiles and regulations pedamotg
Urs©plimey Actions by the Water
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Moir, fax or mail the
Ito:
Mail or free copy to Ike
LAJ I Z I TOO ch h work Phone#: ( Y) 3 C, I
Date:
a Bade up Operator m Responsible Charge ter the facility noted I uudmimd and will abide by the
responaibilitict of the HU ORC as set forth in 1 SA NCAC 086 .0205 and failing to do so can result in
olhotion Cwttol System Opi alors Certification Commission.,"
WPCSOCC, 1611 Maul Service Ceder, Raleigh, NC 27699-1611 MEC 919.W 64fl
Asheville
2090 US Ilwy 70
Swannanoa 28778
Farr 0211.299.7043
Flume: 828..2116.4500
Fayetteville
225 Owen St
Suite 714
Fayetteville 28301.50
!era 918a186 7S7
Phone: 9I0_43133N
Wiaribigten
127 Cardinal
Warningt= 28
1►rrr 118a511.2111
Fame: 91C796.7113