NC0062961_ORC Designation Form_20220614

JUN/14/2022/TUE 04:07 PM FAX No, P,008
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
press rAB to enter information
Permittee Owner/Officer Name: Paul Edward Isenhour, as Signatory Authority
Mailing Address: P.O. Box 1167 Phone; 828-898-6277
city: Banner EIk state. NC zip: 28604
Email Address: [e-mail]
Signature: - y Date:
Facility Name: -7jNE'CA5Tt_e- WWTV Permit# jr�C 00tvgg4�
County: A-V
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
WW
Facility Grade:
II Q
OPERATOR iN'RESP.QN5IBLE'CHARGE.(l7RC}
Print Full Name: Glenn Burleson Jr Work Phone: [phone]
Certificate Type: WW
_M Certificate Grade: 11 El Certificate #: 1011973
Email Address; [e-mail] ti
Signature:
Effective Date: le-75y-z12—
certify that l agree to my designation as the Operator in Responsible Charge for the facility noted. [understand and will abide by the
rules and regulations pertalning 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 Waterpollutlan Control System Operators Certification Commission."
- --
,BACKUP;ORC :
Print Full Name: Paul Edward Isenhour Work Phone,828-898-6277
Certificate Type: WW
El Certificate Grade: IV ED Certificate #:13154
Email Address: [e-mail]
Signature: 4W � Effective Date: 6—iq- z �Z_
"! certify that ! agree to my designation as a Back-up operator in Responsible Charge for the facikty 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."
Mail, fax or email WPCSOCC,1618 Mall Service Center, Fax: [phone] Email: cettadmin@.ncderir.gou
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 Dr.
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 2,8115 Raleigh, NC 27609
Fax.,828-299-7043 Fax:[phone] Fax:[phone] Fax:[phone]
Phone: [phone] Phone: [phone] Phone: [phone] Phone: [phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq. Mall
127 Cardinal Dr.
45 W. Hanes Mall Rd.
Washington, NC 27889
Wilmington, NC 28405-2845
Winston-Salem, NC 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone! 252-946-6481
Phone. [phone]
Phone. [phone] Revised412016

JUN/14/2022/TUE 04:07 PM FAX No,
P. 009
WPCSOCC operator Designation Form (continued)
Facility Nerve: `VNFLA STG E INVVTP Permit #:
NC. b b(:?Aj �
BACK1Jp.t7RC
Print Full Name: Brandon K, Hughes Work Phone:[phone]
Certificate Type: WW
ED Certificate Grade: Ill [A Certificate •#:999265
Email Address: [e-mail]
Page 2
Signature: Effective Date: i<i'/•� 2�
"I certify that I agree to my designatloh as a Rack -up Operator in Responsible Charge for the facility noted. I understand and will ❑bide 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 Actionsby the Water Pollution Control System Operators Certification Commission."
< BACKUP QI�C
Print Full Name: Rex Robert Woody Work Phone:[phone]
Certificate Type: WW
Email Address:
l Certificate Grade: 11 a] Certificate #:988319
Signature: l 7::2 wogv2z Effective Date. /y z2-^
"I certify that I agree to
y designation as a Back p Operator in Responsible Charge for the facility noted. i understand rind will abide by
the rules and regulatio fps pertaining to the responsibilities of the ORC as set forth in 25A NCAC 08G .0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators CertWcatlon Commission,"
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
BACKUP '6ItC
Certificate Grade: Select
Work.Phone:
Certificate #-
Effective Date:
"I certify that I agree to my designation as a flack -up Operator in Responsible Charge for thefacility 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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate 9:
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 setforth In 15A NCAC 08G .0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
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