WQ0004797_ORC Designation Form_20230216

LASSONDE PAMPAS Lassonde
Water Quality Regional Operations
Asheville Regional Office
Melanie,
Enclosed is the form to add Conor Davis Martinez, Certification # 1011899 as a second Backup
ORC to Clement Pappas NC LLC Permit WQ0004797. I also Emailed the original to Raleigh.
Thank You
Dale I Wolfe
125 Industrial Park Road, Hendersonville, NC 28792 • [phone] • Fax [phone] • www.lassondepappas.com

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: Blake Kehoe
Mailing Address: 125 Industrial Park Rd
city: Hendersonville
Phone: [phone]
State: NC Zip: 28792
Email Address: [e-mail]
Signature: Date:
Facility Name: Clement Pappas NC LLC
Permit # W00004797
County: Henderson
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM,.
Facility Type: SI FEB 16 2023
Facility Grade:
Select
OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Dale Irvin Wolfe
Certificate Type: SI 0 Certificate Grade: Select
Email Address: [e-mail]
'! ,ality Regional
vole eg10,�,,
Work Phone: [phone]
Certificate #: 987551
Signature: C��r'/A..� Effective Date:l!�'J�
"I certify that i agree to my designation as the Ope ator 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."
��- A� ✓ BACKUP ORC
Print Full Name: Fredrick Brooks Ferguson Work Phone:[phone]
Certificate Type: SI [] Certificate Grade: Select Certificate #:1002070
Email Address: [e-mail]
Signature: tiResponsible
Effective Date: 4WA` 0V/
`i certify that I agree to my designation as a Back-up Operator 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
WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to:
Raleigh, NC 27699-1618
Mail or Fax
Asheville
Fayetteville
Mooresville
Raleigh
a COPY to:
2090 US Hwy 70
225 Green St., Suite 714
610 E. Center Ave,, Suite 301
3800 Barrett Dr.
Swannanoa, NC 28778
Fayetteville, NC 28301-5043
Mooresville, NC 28115
Raleigh, NC 27609
Fax:[phone]
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington naq. Mall
127 Cardinal Or,
45 W. Hanes Mall Rd.
Washington, NC 27889
Wilmington, NC 28405-2845
Winston-Salem, NC 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone: [phone]
Phone: [phone]
Phone: [phone] Revised 412016

WPCSOCC Operator Designation Form (continued)
Facility Name: Clement Pappas NC LLC Permit #:
WQ0004797
BACKUP ORC _
Print Full Name: Conor Davis Martinez Work Phone:[phone]
Certificate Type: SI _ ED Certificate Grade: Select
Email Address: conor,[e-mail]
Certificate #:1011899
Page 2
Signature: , yam%,, ,.� Effective Date:,r �®
"1 certify that i agree to my designation has o 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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"1 certify that i agree to my designation as a Bock -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."
BACKUP ORC
Print Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature:
Effective Date:
"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."
BACKUP ORC --_
Print Full Name: _ Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective 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 ORC asset 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."
Revised 412016