NC0071242_Other Agency Documents_20220617

Signature:
Watcr Pollution Control System Operator Designation Form
wPcsocc
NCAC ISA 11G
Statc:
Tony Konsul
Facility Name: /2_ 1\i'e
SUBMIT A SF.PARA
TvrGrade:
Operator in Respon ibk Ckarge (ORC)
Print Full Name: 14et 1 r1
Certificate Type / Grade /N
Signature:
"1 certify tbat 1 agree to
and regulations pertaining
Actions by the Water Pollution Con
Back -Up Operator in Responsildk
Print Full Name:
Certificate Type / Grade / Number:
Signature: )/
"1 certify that 1 agree to my deli
rules and regulation pe rtainmg In
Disciplinary Actions by the Water
Mail, fax or mail the
original to:
Mail or far a copy to the
aPProPiale Regional Oifi
FO
Permit#: AU 6,6 c�7 / zy a
FOR EACH TYPE SYSTEM!
Surface Irrigation
Land Anplcation
- L1 77
(131zz
Charge fix the facility noted. I tmdersland and will abide by the rules
in 15A NCAC 08G .0204 and Oiling to do so can result in Disciplinary
Commission."
�t2
Work
Operator in Responsible Charge for the fa y noted. I understand and will s1n& by
responsibilities ado BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
olhrtion Control System Operators Certification Commission."
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WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fan: 919.807.6492
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Mae+restile
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Vase 784.663 40
thane: 7114463.1691
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Wsughtown
5-2845 Winston-Salem271in
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Pbaar 919.711.42M