NC0060224_ORC Designation Form_20220614

1UN/14/2022/TUE 04:05 PM FAX No, P,002
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press rA9 to enter Information
Permlttee Owner/Officer Name: Paul Edward Isenhour, as Signatory Auth
Mailing Address: P.O. BOX 1167
City: Banner Elk state: NC
Phone: [phone]
zip: 28604
Email Address: paul,[e-mail]
Signature: � y Date: - j . -z -
s
Facility Name-, &tJA5 RP4E WW-[° Permit # N 0, 00(t02.2±[
County: ug-or
YOU MIDST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Typo: WW Q
Facility Grade: 111 19
QPECtATQIll N RES0.01'S1HLE CHARGEIORC) ..
Print Full Name: Glenn Burleson Jr Work Phone: [phone]
Certificate Type: WW
Email Address:
1l Certificate Grade: 11
0 Certificate #: 1011973
Signature: V„fA/1 Effective Date: -ly-z�
"i certify that/ agree to my designation as the 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 086.0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
. �ACKUP CiaC',
Print Full Name: Paul Edward Isenhour Work Phone:[phone]
Certificate Type: WW 0 Certificate Gracie: IV Certificate #:13154
Emai! Address: [e-mail]
Signature: Effective Date: (v l
' certify that I agree to my designation as a Back-up Operator In Responsible Charge for the facility noted. I understand and will ablde 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 the Water Pollution Control System Operators Certification Commission,"
Mail, fax or email WPCSOCC, 1.618 Mail Service Center, Fax. [phone] Email: [e-mail]
ORIGiNAL to: Raleigh, NC 27699-1618
Mall 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 Dr,
5wannanoa, NC 28778
Fayetteville, NC 28301-5043
Mooresville, NC 28115
Raleigh, NC 27609
Fax: [phone]
Fax: [phone]
Fax.,704-663-6040
Fax, 919-571-4718
Phone: [phone]
Phone:[phone]
Phone:[phone]
Phone.[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr,
Wilmington, NC 28405-7845
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax, 336-776-9797
Phone: [phone]
Revised 412016

1UN/14/2022/TUE 04:05 PM FAX No,
P. 003
WPCSOCC Operator Designation Form (continued)
Facility Name; WAS 151 WV4 f Permit M
Page 2
BACK' UP' QRC
Print Full Name: Brandon K. Hughes Work Phone:[phone]
Certificate Type: VIIW Certificate Grade: III Certificate #:999265
Email Address: [e-mail]
Signature_ Effective Date:'/Sr Z -z—
"i certify that I agree to my designatiW 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 x5A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control system Operators Certification Commission."
RAKUp 0�tC
Print Full Name: Rex Robert Woody Work Phone:[phone]
Certificate Type: WW Certificate Grade: 11 Certificate #:988319
Email Address:
Signature: Effective Dater
certify that i agree to y designation as a Back p Operator in Responsible Charge for the facility noted. 1 understand and will abide by
the rules and regulatio s 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 the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"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 asset forth in ISA NCAC o8(; , 0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
i4rVkilp ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"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,"
Revised 412016