WQ0014868_ORC Designation Form_20170626

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Water -Pollution Control System operator Designation -Form � �iyg(o6
3 WPCSOCC�p�/S
NCAC 15A 8G :0201
Permittee Ow>ier/Officer Name:
.Mailing Address:
State:. PC Zip: 2 t�J���7 - Phone #: (i10)
Email address: \<,Ac \ t µ/. SN1 cr,)
,,�/
Signature: i✓. �. L'Lv'�� Date:
....................... ..................................;.......... :.....:...........................
Facility Name:5AIIViiFGV` -TdQ,146CCPer...........
�0,....
• ' � t�lf>t� -
SUBMIT A SEPARATE FORM FOR. EACH TYPE SYSTEM!
Facility Type & Grade:
Grade Grade
Biological WWTP Surface Irrigation
Physical/Chemical Land Application_
Collection System
..:
........................................................................................................................,
Operator in Responsible Charge (ORC)
Print Full Name: _ bL,: ,C, ry, g
Certificate T e /Grade / Numben .��h �e� %5 96 Work Phone #: OP. 1 . b-'Ia - 'qSl
Signature: Date: - (� 0�6 ' '/ r7
"1 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 setforth. 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:
Certificate Type L Grade / Number:. Work Phone #: { 910) W P) , 3 /,2, 7
Sig4nature: Date:.
"I certify at 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 b the Water Pollution Control System Operators Certification Commission."
.......... ............................ ......................................................................... :.............. :............
Mail or Fax to: WPCSOCC .
1618 Mail Service Center Please send -a copy to -your appropriate Regional Office
Raleigh; NC 27699-1618.
as listed below
Fax: [phone]
Regional Offices: Asheville:
Fayetteville.
Mooresville
Raleigh
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 2811.5
Fax:.[phone]
Fax:910:486.0707
Fax:[phone]
Washington
Wilmington
Winston-Salem
9.43 Washington. Sq Mall
127 Cardinal Dr
585 Waughtown St
Washington 27889
Wilmington 28405-2845
Winston-Salem 27107
'Fax:[phone]M
Fax:[phone]
Fax :[phone].
Revised 6-2012

•
Facility Name: Tie'— .�1 CCU U ►� I St o Permit #:
.................................................................................................................................................
Back -Up .Operator in.Responsible.Charge (BU. ORC)
Print Full -Name: T.�Ju' .oj i
Certificate Type /Grade /Number: t k- i Work.Phone #: ( *) Z 5-,4M1
-Signature: `-�1 ( �'�L-----= Date: (c Zb LJI`�
"I certify that I agree to my.designation as a Back-up Operator in Responsible Charge for the facility noted. l understand -and will abide by the rules
and regulations pertaining to the responsibilities of the BU' ORC as set forth in.15A NCAC 68G .0205 and failing to-do so. can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
........................:...................................:..........:..........a............
Back=Up Operator hi Responsible Charge (BU-ORC)-
Print Full Name:
Certificate Type / Grade / Number: Work Phone #:
Signature: Date:_
"I 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. 15A NCAC 08G .020.5 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. 1 understand and mill 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. OperaforsCertification Commission."
......................................... ....................... ........... :.......... :.......... :...... .... :............................. .........
Back. -Up Operator in.Responsible Charge (BU ORC)
Print Full Name:
Certificate -Type / Grade / Number:
Work Phone M f
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 15A NCAC 08G .0205 and failing to do so can result in Disciplinary
Actions by. the Water Pollution. Control System -Operators Certification Commission."
......................................................................................................................................:...............:..................
Revised 6-2012

v
c
Barber, Jim
From: Weaver, Tim <[e-mail]>
Sent: Thursday, June 29, 2017 1:27 PM
To: Honeycutt, Tony; Barber, Jim
Cc: Harris, Robert; Cain, Donna; Russ, Dwayne; Mains, Ronald
Subject: Land App ORC Designation Form for Smithfield - Tar Heel - Permit #WQ0014868
Attachments: ORC Designation Form - Smithfield - Tar Heel - Land App Permit NC WQ0014868 -
Revised 2017-06-29.pdf
Gentlemen,
Please find attached a copy of our latest ORC Designation Form for our Land Application Permit #WQ0014868.
This designation is submitted as the previous ORC, Jeffrey Musselwhite, has retired and is no longer with the company.
As instructed on the form, I will also be mailing a hard copy to the Raleigh office, and to the Fayetteville Regional Office,,
but I wanted to send this so that you are aware of this change in a more timely fashion.
Please contact me if you have any questions or concerns.
Tim Webver-
Wastewater Supervisor
[phone] tel
[phone] fax
[phone] mobile*
[e-mail]
*preferred
Smithfiehi
600A €ook'Respor+siv(!
Smithfield Foods
15855 Highway 87 West
Tar Heel, NC 28392
www;smithfieldfoods.com
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57-M55-K,00) and the delete fh.r c0011-nunication and dr,siroy all Carlos Thereof
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