WQ0029475_ORC Designation Form_20221029

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address: QyjAr, CA-.
City: Carr. State: I.. , Zip: 2" l \ _ , Phone #: cW)-- a.'?0-1tAxa.
Email address: *Cji,11-y-itvit AS e Q Uflrr tCC i. CIOyr
Signature: � � Date: g
Facility Name: r• Permit #:
County: Or L
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Ourface irrigation') Land Application
Operator in Responsible Charge (ORC)
Print Full Name:-\C,Y)3Q\ CAU-e \' Email: reed o ulcA\ C (Y- egiCCI . CeitM
Certificate Type / Grade /Number: /0e) 5-8 3 Work Phone #: q10-.tag (41.1(�
Signature: .[ ..--/ Date: 3%/z/ze o
"1 certify that I agree to my designation as the 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."
Back -Up Operator in Responsible Charge (BU ORC) , I I
Print Full Name: tror-0. gyro► bfl Email: r 1bva FiQY1txG1Gis( arY1eC'icc1.cor`r1
C q f gci
Certificate Type / Grade / Number: Work Phone #: � �a - �-1��- c1�N�
Signature: .o-f -' Date: Z/- /' 2 "
"1 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,"
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadminQnedenr..ov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office. 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax: [phone] Fayetteville 28301-5043 Mooresville 28115 Fax: [phone]
Phone: [phone] Fax: [phone] Fax: [phone] Phone:[phone]
Phone: [phone] Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W. Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax: [phone] Fax: [phone] Fax: [phone]
Phone: [phone] Phone: [phone] Phone: [phone]
Revised 05-2015

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: A.C.i��"i
Mailing Address: 3,h t '*-
City:
Email address: 'j'1 i, C _CX—) �1-r 1C(3,
Signature: _ "1tNU�, F Lr Date:
•
Permit #: Ca..
Facility Name:
State: MC, Zip: 715'\ ( - Phone #: C\\c' - Z-1C - 1 -%\-
�'r, � r
County:
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE): ,2
Biological j Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: %--110\P\(::-& ,_ P>>
Email: i'1'1{�C�t�e e11 C91"'%
Certificate Type /Srade / Number: t,✓u r. 10074,6 Z Work Phone #: GMI'�-1 2u.— �G"1 L
Signature:
Date: 7 z `. —19
"1 certify that l 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 ofthe 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: ( S,r pon Email: rtf. ; i C-w t'�eC?tt"�f tt�t tit-tiP_�iCC',. .
Grade Number: •NL)-i 113G` ���`l Work Phone. #: 1 — ?�►—C
Certificate Type / / � .
Signature:
Date: 7 • .%l rV / I
"1 certify that 1 agree to my designation as a ack-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 1311 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."
Mail, fax or email the
original to:
Mail or fax a cony to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center,
Email: certadmin(a)ncdenr.eov
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
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suitt 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: °919.571.4718
l'Itf R 0 101GE
AUG 21 2019
DWR SECTION
OPEP,ATOR CERTIFICATION PROGRAM
Revised 05-2015

WPCSOCC Operator Designation Form, cons.
Facility Name:
Permit #:LI,XQ,L'yCit-fi 5
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: L'n'v-]I'C\ r e r Email: r100 C1Cli ICcj -6cc Gan
Certificate Type / Grade / Number:l 1:10 _Q0 % 5 Work Phone #:.eIts—qa:9 ! (, (,
Signature: "$4- /4 Date: �'`/ 2 _19 j `pt- i
"1 certify. that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and uill 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:
"1 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
rites and regulations pertaining to the responsibilities ofthe 'BU ORC as set forth in 15A NCAC 0.8G .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:
"1 certify that 1 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 BU ORC as set forth in I5A 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:
"1 certify that 1 agree to my designation us 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 BU ORC as set forth in 15A NCAC 08G .0205 and railing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 05-2015