WQ0004797_ORC Designation Form_20230216 (2)

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.lassondepappasxoni

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A BG .0201
Press TAB to enter information
Permittee Owner/Officer Name: Blake Kehoe
Mailing Address: 125 Industrial Park Rd
city: Hendersonville State; NC
Email Address: [e-mail]
Signature:
Facility Name: Clement Pappas NC LLC
Phone: [phone]
zip: 28792
Date:
Permit # W00004797
County: Henderson
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEMi i
Facility Type; ISI 6 2023
Grade: I Select
^i;ality Regionel Oppr�';^n
OPERATOR IN RESPONSIBLE CHARGE (ORC) ,cvii a eglai,a�
Print Full Name: Dale Irvin Wolfe, Work Phone: [phone]
Certificate Type: SI ED Certificate Grade: Select
Email Address: [e-mail]
Certificate #: 987551
Signature: �,r, Effective Date: ?1191rage a
ll
"I 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 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: Fredrick Brooks Ferguson Work Phone:[phone]
Certificate Type: 81 1-j Certificate Grade: Select Certificate #:1002070
Email Address: [e-mail]
Signature:
Effective Date: 4211VAIWI
"I certify that I agree to my designation as a Back-up Operator i rr�'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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone]
ORIGINAL to: Raleigh, NC27699-1618 -
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington arq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC Z7889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:3,36-776-9797
Phone:[phone] Phone:[phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: Clement Pappas NC LLC Permit #: WQ0004797
BACKUP ORC
Print Full Name: Conor Davis Martinez Work Phone:[phone]
Certificate Type: SI El Certificate Grade: Select
Email Address: [e-mail]
Certificate #:1011899
Signature:
Effective Date:
"Icertify thati agree tomydesignatin 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:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I 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."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate #:
Signature _ 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 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 cert/fy 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 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."
Revised 412016