NC0062413_ORC Designation Form_20220614

JUN/14/2022/TUE 04:06 PM FAX No, P,006
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCQ
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 Phone: [phone]
city; Banner Elk State: NO zip: 28604
Email Address: [e-mail]
7gmail.com
Signature: / Date: ( /z/. -L-4,
Facility Name: LIN V 1 GL .1b(46- ' DVAMN C W 9 WmAP Permit # t.00 (v 9 yl a
County: Imo,
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II 101
OPERATOR lN'RESPONSIBLE CHARGE (ORC}
Print Full Name: Glenn Burleson Jr Work Phone: [phone]
Certificate Type: WW ZI Certificate Grade: II Certificate #: 1 01 1973
Email Address: sonnyb1 07outlook.cam
Signature: :LEffective Date: —
"I certify that I agree to my designation as the Operator i R sponsible 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."
SACKUP,ORC _
Print Full Name: Paul Edward Isenhour Work Phone:[phone]
Certificate Type: WVV l Certificate Grade: IV
Email Address: pau1.issnhour gmail,com
a certifiti�te #13154
Signature: ., Effective Date:
i certify that l 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 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
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone:[phone]
Washington
943 Washington Sq. Mail
Washington, NC 27889
Fax: [phone]
Phone:[phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone: [phone]
Mooresville Raleigh
610 E. Center Ave,, Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone]
Phone:[phone] Phone.[phone]
Winston-Salem
45 W. Hanes Mall Rd,
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone] Revlsad 412016

1UN/14/2022/TUE 04:06 PM FAX No,
P. 007
WPCSOCC Operator Designation Form (continued)
Facility Name; U01/1 LL[ 71,1%e GpL}"Q_ CL()G wL rfflPermit ##:
Page 2
BACKUP.ORC
Print Full Name: Brandon K. Hughes Work Phone:[phone]
Certificate Type: WW Certificate Grade: III Certificate #:999265
Email Address: [e-mail]
Signature: Effective Date: 17-/9-7 2
1 certify that I agree to my designate 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."
Print Full Name: Rex Robert Woody Work Phone,828-467-7948
Certificate Type: WW El Certificate Grade: II Certificate #:988319
Email Address:
Signature: 6 Effective Date:
"1 certify that I agree t4r]
designation as a Back p Operator in Responsible Charge for the facility noted. 1 understand and will abide by
the rules and regulatioertaining to the responsibilities of the QRC as see 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.'
.. sACKUP ORc:
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date;-
'/ certify that! 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 QRC as set forth in 15A NCAC 08G .0204 and falling to do so can result in
bisciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
BACK P.QRC
Print Full Name: Work phone:
Certificate Type: Select Certificate Grade: select Certificate #:
ErOl Address:
Signature:
Effective Date:
"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 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."
RRVIsed 412016