WQ0002638_ORC Designation Form_20131001

From:. 10/22/2013 22:18 #275 P.001/002
Permittee Owner/Officer Name:
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G.0201
i ot�r� c� f Ptnt; e2
Mailing Address: 55 /J . groctA \i
City: Arlen
State:Ak, Zip: 21E01-
Phoneit:(Ilq) 639-aO"1t
Email address: COOK CI. to • ' ,e O i'
Signature:
Ozo
Date:
Facility Name: 1 jjr\ Oc Av if t - Permit #: Waoce) a438
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tvne/Graile:
Biological WWTP Surface Irrigation
Physical/Chemical Land Application
Collection System
x
Operator in Responsible Charge (ORC)
Print Full Name: 44461a2,7 ice 4 7;:I 4,5AWL'S
Certificate Type / Grade / Number: S X 233.5.6v Work Phone #: (YI cF) t J 7 - 2 49 2
Signature: 1 Date: f- 2 Y- /.3
"I certify that I agree to my designation as the 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."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: 3eo"+ or . n,Spote%
Certificate Type / Grade / Number: S i ) g5-16, Work Phone #: (9 l`1) , s2.0. 3 2(6 "1
Signature:.. �1„ '• Date: It, )
"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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mari fax or email the
original to:
Marl or fax a copy to the
appropriate Regional Ofj'rce:
WPCSOCC, 1618 Mail Service Center,
Ematl: cettadnihi ncdenneov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Raleigh, NC 27699-1618. Fax: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 02-2013

From: 10/22/2013 22:19 #275 P.002/002
Facility Name: / O o F j j.e t - cla^ Permit #: Li-UR 0cr) a403 $
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: ReAtut X00r..4i (.5011- 1't—
Certificate Type / Grad / Number: S J . 1991
Signature:
Work Phone #: (9 11 [3 94071
Date: 16 -I -) 3
"I certify that I agree my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations eMining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: 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 oftheBU ORC as set forth in 15ANCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: ' 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 BU ORC as set forth in 15ANCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BIT ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: 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 BU ORC as set forth in 1SANCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 02-2013