NC0082821_Response to Notice_20220725

RECEIVED/NCDEQ/DWR
JUL `L5/?
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
WQROS NCAC 15A 8G .0201
ESVILLE REGIONAL OFFICE TAB to Navigate Form
Facility Name:
STATESVILLE FERTILIZER PLANT
Facility Type: PC
Permit # NC0082821
Facility Grade: I SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Zachary Garlick
Email Address:
[e-mail]
Permittee Signature:
Full Name: Zachary Clay Garlick
Email Address•
SAVW
[e-mail]
Certificate Type. PC
Signature:
Full Name:
RC
n Responsible-C,
Certificate Grade: I
4u71,Ui.�
Date: ! ! 11 f o'.
Work Phone: [phone]
Certificate #: 1011862
Effective Date: 1
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fi certify that 1 axjree to my designation as the Operator in Responsible Charge for the facility noted. ( 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."
Thomas Foster Haynes
Certificate Type: PC
up ORC
Certificate Grade: I
Work Phone: [phone]
Certificate #: 990461
Signature: ltOmouS tkA Iit,t,S Effective Date: 7/12/2022
"I certify that I agree to my designation as a Back-up Operator in Responsible 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."
Full Name:
Backup ORC
Certificate Type: Select
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"1 certify that I agree to my designation as a Backup Operator in Responsible 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 con result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 I FAX: [phone] I [e-mail]
Mail or fax a COPY to: ; Mooresville-610 E. Center Ave., Suite 301, Mooresville, NC 28115 1 FAX: [phone] I PH: 704-663-1699
Revised 3/2019