WQ0002638_ORC Designation_20160405

Water Pollution Control System Operator
WPCSoCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: 6 v\ a ,ern „t r•/
Mailing Address: p' ' B o ,
i'
esignation Forin
n l-e.1
City: Airt%i e f _ State: Ai.t Zip: a 1$'U\ - Phone #:
Email address: P L ) o:r^ %. S e.� q+*`.g t'C r, b
Signature: ��J. r✓Ltc�
Date: fr s"-- / C
Facility Name: I t4"_ o f ,1�,trtq i .e {"
County:\ /`Taft \ _*- i •?
Permit#: (,L) () 000 V,638
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical siSurface Irrigation Land Application.
Operator in Responsible Cbarge`(ORCI) j�
Print Full Name: raln t5eek �J O v15 t7 Email: A.Oi'iu on e Olds c cf , ov.
5 1 01t S iC. Work Phone#: 911 s a 0
Certificate Type / Grade / Number:
Signatures .,
Date: L'(_ _ < <a
"1 certify that I agree to my designation as the. Operator in Responsible Charge far 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: 02c>64:1-1 /41;r23 Email:
Certificate Type / Grade /Number "44/ -.233 Sla' Work Phone #: 6-'463 g 2C5 •7(_
Signature: `t?t? . /_.tcL 7 Date: y;s�'I6
"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 Coritrol System Operators Certification Commission."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax:.[phone]
Eivail ceriadmin(h?nedenr:�o
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax [phone]
Phone: [phone]-
Washington
943 Washington Sq Mall
Washington 27889
Fax: 252.946,9215
Phone: [phone]
Fayetteville
225 GreenSt,
Suite-714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845.
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 30.1
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450. W. Flans Mall Rd
Winston Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015

WPCSOCC Operator Designation Form, cone.,
Facility Name: I G W A
Permit 0004103S
Back -Up Operator in Responsible Charge (BU ORC) -
Print Full Name: Y1V'-j UekYov5. 60g Email: \Cba (& ,Of
Certificate
ii?
Signature:
/ Number: 5_r- i gs-y U Work Phone #: 119 " 6239` 0:0
Date: - S"
"I certify that i agr€ 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 ORS 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: Email:
Certificate Type / Grade / Number: Work Phone #:
Signature: .Date:
"I certify that I agree to my designation as aBack-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."
Back -Up Operator in Responsible. Charge (BU ORC)
Print Full Name: Email:
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 tothe 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 (BU ORC)
Print Full Name: Email:.
Certificate Type / Grade /Number: Work Phone #:,
Signature: Date:
"I certify that I agree to my,"designation its a Back-up Operator in Responsible.Cbarge. for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the B.0 ORC as set forth in 15A NCAC 08G .0205• and failing to=do so can result in
Disciplinary Actions by the Water Pollution Control Systein Operators Certification Commission. "
Revised 05-2015