NC0085154_ORC Designation Form_20230322

3/21/2023 13:59 T-04:00 TO: [phone] FROM: 8286582362
NCAC 15A 8G .0201
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Facility Name: Town of Weaverville
Permit # NCO085154
Facility Type: PC a Facility Grade: I 7] SUBMiTASEPARATE FORM FOR EACH CLASSIFICATION
Permittee owner/officer Name: Town of Weaverville / Selena Coffey
Email Address: [e-mail] //
Permittee Signature: �Y I 1 Date:
Full Name: Randall Wilson Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: PC Certificate Grade: I Certificate #: 1004637
Signature: ale-/ (/ Effective Date:
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility not�tand 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
Full Name: Ronnie Edwards Work Phone: [phone]
Certificate Type: PC
Certificate Grade: I
Certificate #: 1013147
Signature: �~ y Effective Date: f j J 2 a
, tthat i agree to my designatio an s 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 ORCt
Full Name: Adrian Lee Hipps Work Phone: [phone]
Certificate Type: PC
Certificate Grade: I
Certificate #: 1013134
Signature: Effective Date: 7 I Z
"I certify t I agree to my de nation 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 jailing to do
so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 I FAX: [phone] [e-mail]
Mail orfax a COPYto: Asheville 2090. US Hwy 70, Asheville,. NC 28778.1 FAX: [phone] PH: 828-29 64500
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