NC0071862_ORC_Designation_20220712

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�/ TER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
�M NCAC 15A 8G .0201
JUL 1 2Q
TAB to Navigate Form
er Quality Regional Operations
Asheville I it�IN69ke Permit #
660 71J&
Facility Ty : WW Facility Grade: 11 SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:Date:
Full Name: q Work Phone:
Ac 6g'—q"0
Email Address:?
Certificate Type: W Certificate Grade: Select Certificate #:
i
Signature: Effective Date:
"i certify that 1 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 con result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name:
Certificate Type:
Signature:
Certificate #: / W
7 certify that 1 agree to my designAi6n afa Back-up Operator in Responsible Charge for the facility noted. i understand and will
abide by the rules and regulations pertaimrg to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinaryy Actions by the Water Pollution Control System Operators Certification Commission."
110
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Full Name: Work Phone:
Certificate Type: WW Certificate Grade: Select Certificate #:
Signature: Effective Date:
"1 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 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 ORIGINAL to: WPCSCCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: [phone]certadmin@a ncdenr.gov
Mail or fax a COPY to: I Asheville-2090 US Hwy 70, Asheville, NC 28778 1 FAX_828-299-7043 1 PH_828_296-4500
Revised 3/2019

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