NC0042358_ORC Designation Form_20220614

JUN/14/2022/TUE 04:05 PM FAX No, P,004
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter Information
Permittee Owner/Officer Name: Paul Edward Isenhour, as Signatory Authority
Mailing Address; P.O. BOX 1167
city: Danner Elk
Email Address: [e-mail]
Phone: [phone]
State: NC Zip: 28604
Signature: bate: (� /y_Z
Fac0ltyName: -RAMS APPLE WJjKLP— Permit# Ji�j
County: p,VN
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
WW
Facility Grade:
�11 Ej
OPERATQR i1V RESP..ON51BLE CHAJGE:(QEcJ
Print Full Name: Glenn Burleson Jr work Phone: [phone]
Certificate Type: WW
_El Certificate Grade: II Certificate #: 1011973
Email Address: sonnyb107@outlook com
e •
Signature: &A � J',� .-i 4 Effective Date:��-lyzz
"1 certify that I agree to my designation as the Operator 11Responslble 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 25A NCAC 08G .0204 and falling to do so can result in
Visciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name: Paul l�dward Isenhour Work Phone:[phone]
Certificate Type: WW 1 Certificate Grade: IV Certificate #:1315A
Email Address: [e-mail]
7gmail.cam
Signature: Effective Date: 6-141- Z 2—
"i 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 responsibllltles 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 WPCSOCC,1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL, to; Raleigh, NC 27699-1618
Mail 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 Or,
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115 Raleigh, NC 27609
Fax: [phone] Fax; 910-486-0707 Fax; 704-663-6040 Fax: [phone]
Phone: [phone] Phone,910-433-3300 Phone:[phone] Phone,919-791-4200
Washington
Wilmington
Winston-Salem
943 Washington Sq. Mall
127 Cardinal Dr.
45 W. Hanes Mall Rd.
Washington, NC 27999
Wilmington, NC 28405-2845
Winston-Salem, NC 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone: Z52-946-6481
Phone: [phone]
Phone: [phone] Revised 4201e

JUN/14/2022/TUE 04:06 PM FAX No,
P. 005
WPCSOCC Operator Designation Form (continued)
Facility Name: ADWS AIMS ww-TP Permit #:
Page 2
BACKUP QfiC
Print Full Name: Brandon K, Hughes Work Phone:[phone]
Certificate Type: WW Certificate Grade: III Certificate #:999265
Email Address: bhughes312 [e-mail]
Signature: Effective Date:
'? certify that l agree to my designate�,,,-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."
Bi4ClCkJP; OPC
Print Full Name: Rex Robert Woody Work Phone:[phone]
Certificate Type: WW ( Certificate Grade: Il Certificate #:988319
Email Address:
Signature:
Effective Date: �y
"I certify that i agree to y designation as a Backup operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulatia s 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,"
1 ACKUP•ORC
Print Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"7 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 setforth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certificatlon Commission."
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:�
Email Address:
Signature: Effective Date:
"1 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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
keV/Sed 412016