NC0078955_Form_20230501_20230501

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FOR-M,
NCAC 15A 8G .0201MECENELL-J.
TAB to Navigate Form MAY 3 Q 20Z�
Facility Name:. CITY OF_DUNN Permit # NC0078955
- L n� U1LOFFICE
Facility Type.: PC,_� „ = Facility-Graife:., I SU9MITASEPARATEFORMFOREACHCLASSIFI[ATION
Permittee Owner/Officer Name: HEATHER THOMAS ADAMS
Email Address:
Permittee Signature:,- Date: �'
Full Name: IAN NATHANIEL STROUD Work Phone: (910) 897�-51 29
Email Address: '[e-mail]
Certificate Type: PC C7 icate ' rade:.I Certificate #: 1003541
Signature: Effective Date:
"1 c tat 1 agree to my designation as the 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 086 .0204 and
failing to do so can result'in Disciplinary Actions by the Water Pollution ControlSystem Operators Certification Commission,"
Full Name:
WILLIAM BENTLY; GREGORY,:::..::_ :V&k,Phone: -(91.0)-`897=5129' ��'
n
rtificate_T e: PC
Ce" . , _ vp Certificate Grade: ca a #: 1008545
Signature:1 Effective Date:
'7 certify that 1 agree to y. esignatio as a ck-up Op tar in Responsible Charge for the facility noted. 1 understand and will
abide by the rules and regulations p ain' to the re nsibilitles of the ORC as set forth in 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Acti� by the Water Pollution Control System Operators Certification Commission."
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select . Certificate #:
Signature
Effective Date:
"I cer* 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 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 ORIGINALtb: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: [phone] [e-mail]
Mail or fax a COPY to: Fayetteville-225 Greene t, Suite 714,M1Fayetteville,, NC`28301-50431 FAX: [phone] PH: 910-433-3300
Revised 312018

14

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Page 2
Facility Name: CITY OF DUNN Permit #: NCO078955
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Full Name: Work Phone:
Certificate Type: Select 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. ! 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 ControlSystem Operators Certification Commission.'
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Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Signature:
Certificate #:
Effective Date -
I certify that 1 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."
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Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select
Signature:
Certificate #.-
Effective Date:
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 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."
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Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"1 certify that l 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."