WQ0039181_ORC Designation Form_20230320

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: QQro✓t Go S
Mailing Address: I q (oo( S4-,.A-e5 ; k 1 rrll Phone: 70`1 — 4 t
City: C leJe`aria( State: Zip: 270 3
Email Address: Cnj`QJ% C rol;A Co ✓ A
Signature: avtot_ Date: 3 13 23
Facility Name: C Q('o I n� / �t 140 � S Permit # Q © �
County: iRoW c, y\
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: Select S L
Facility Grade: Select
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Lyn h al�t':Ige_ Work Phone: Toy — 13 j — 52 ke
Certificate Type: Select , Certificate Grade: Select IL Certificate #: 9 3 7 79
Email Address: r 0 q tea; i , o�
Signature: Effective Date: -3
"1 certify that 1 agree to my designation It&"he Operator in Res nsible 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: yo�y\ c q C.y1 berg Work Phone: 70 cf — 2 13 ` 3 3 7
Certificate Type: Select ST `` Certificate Grade: Select T Certificate #: , OO 6 7 (
Email Address: �0.1' Ca Co I`ngti lam. LoM
Signature: f Effective Date: 2 3
'? 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."
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
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Revised 412016