WQ0020409_ORC Designation Form_20231101

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Little Creek Resource Recovery Facility Permit #
WQ0020409
Facility Type: WW 0 Facility Grade: Select SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Lisa Joseph
Email Address: [e-mail]
Permittee Signature: Date: / (J
ORC
Operator in Responsible Charge
Full Name: Kelvin Brown
Email Address: [e-mail]
Work Phone: [phone]
Certificate Type: WW E] Certificate Grade: IV 0 Certificate #: 998576
1,0112,02-1
Signature: `� Effective Date:
"I certify that l 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 08G .0204 and
failing to do so con result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Jennifer Holmes Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 992797
Signature: j M%�� Effective Date: )0 1 IZO23
"Icet
th t agree to my designation os a Back-up Operator in Responsible Charge for the facility noted. I understand and will
obi th r les 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: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"9 certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted, l understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC O8G .0204 and failing 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 27699-1518 1 FAX: [phone] [e-mail]
Mail or fax a COPY to: Choose DWR Regional Office that has coverage of this facility.
Revised 812023