NC0021253_Other_20230330

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer,Name: City of Havelock/Christopher McGee
Mailing Address: PO Box 368
city: Havelock
Email Address: [e-mail]
Signature:
Facility Name: City of Havelock WWTP
County: Craven
Phone: [phone]
State: NC Zip: 28532
Permit # NCO021253
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: IV
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Rodney George Work Phone: [phone]
Certificate Type: WW
Email Address: rg
Certificate Grade: IV Certiflcate #: 1009761
us
Signature: / Effective Date: ..3 —42�p23
'I certify that/ agree to my desigl2loa, a 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: Jeffrey Jarman Work Phone: [phone]
Certificate Type: WW
Email Address: moonwalk@gmail.
Signature:
Certificate Grade: Select Certiflcate #:13491
Effective Date: J 1Z C./ L
'I certify that I agreelt`o my desTgnatlo6,ds a Back-up Operator In Responsible Charge for the faculty 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.'
Mall, fax or emall WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email_: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone: [phone]
Mooresville Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609
Fax: [phone] Fax: [phone]
Phone:[phone] Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone] Revised 42016

WPCSOCC Operator Designation Form (continued)
Facility Name: Permit M
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature:
Effective Date:
Page 2
"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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certlflcation Commission."
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
BACKUP ORC
Certificate Grade: Select
Work Phone:
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 as set forth /n 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:
Signature:
BACKUP ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"Icertify 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 NC,4C 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/ 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 falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 412016