WQ0020409_ORC Designation Form_20231001

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name:
L I Slz
a/?
Mailing Address:
Po, &x
90
Phone: O//q-
City:
/��t
State: /V[ Zip:
Email Address:
//. o
occiob 61Iev,
h /7c 10
Signature:
Date: r✓r p __2rJvl
Facility Name: Al/U C'LJ3� iYt'!� lie-Te"f.:rc
,n
e Ai P�ai�PY
�/, Permit # "o -
County: 10&.
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Select 1/(
Facility Grade:
Select
Print Full Name:U'
Certificate Type: Select Bi a
Email Address:
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Certificate Grade: Select 4
r4 ( V�,,n4.
Work Phone: cf (', I � � ;, G `% z--
Certificate #: I Lj
Signature: �- - Effective Date: Oct i
"I certify that I agree to my designation as the 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: Aj ck- e- ( Work Phone: q lei 4l9 Le_ 3Ca ?3
Certificate Type: Select , Certificate Grade: Select L4 Certificate #: 9 a ci -7 3 3
Email Address: ��C,.y ,{, 1(( �ct� e «, 12 ve , q o ✓
Signature: Effective Date: (tJG-t- 1 3
"1 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 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] Erna*. [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]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name:
Mailing Address: ) 1 Phone: 7 - zW
City: [I/ State: Zip: 49 2M_
Email Address: Ace _ IncnnAr01,1i%AiIn1�"/ 1?,,,:1
Signature
Date: /1 o7 140
i
Facility Name: 4111le Cr'(? ek- _ elel-'146:l%r Permit# �V/q 60_�
County: Na _
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Select Zj%. 7 fjtJ
Facility Grade:
Select
Print Full Name:
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Gq___�
Certificate Type: Select K a Certificate Grade-, Select
Email Address: jV�G�r t .mot. t � �' c : �
Work Phone: I 1 114 3 (a-7Z—
Certificate #: lj o 30-
Signature:, Y Effective Date: / �9-0a3
"i certify that I agree to my designation as the 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: A 4-OL'ie-I It _ Work Phone: Ot 31, 73
Certificate Type: Select 3 j p Certificate Grade: Select i- j Certificate #: °I 9 ` 7 33
Email Address: Ij 6? je— I -e,' i� 4)e, ycLJ
Signature: )Q�2Effective Date: Oc-7- 1 a O Q3
"I certify that/ agree to my designation as a Back-up Operator in Resp Bible 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."
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
Wilmington
Winston-Salem
943 Washington Sq. Mall
127 Cardinal Dr.
45 W. Hanes Mall Rd.
Washington, NC 27889
Wilmington, NC 28405-2845
Winston-Salem, NC 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone: [phone]
Phone: [phone]
Phone: [phone] Revised 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address:
City:
Email Address:
Signature
Press TAB to enter information
State: L
Facility Name: S�yJ/ Permit #
County: %Ja
Phone: ,r'�% 99l
Zip:
Date: / 3C ho
Vq OD-3_'�_ISI
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Select 1�
Facility Grade:
Select
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: (f bN -- Work Phone: 641 1 i 72—
Certificate Type: Select 13� a Certificate Grade: Select
Email Address: A(zrEG Aa_ (+V-\. 6) r-c-lezAn C_, v
Signature:
L_�
Certificate #: 6N qo 3 e
Effective Date: O c, 14
"I certify that I agree to my designation as the 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: AJcj Work Phone: q t01 c?9L 3G--73
Certificate Type: Select 13 r` p Certificate Grade: Select Certificate #: '� 9'�"! 7 1_3
Email Address: A, JFn 4- L_u,v, r- e3L,,.,t/( 4o eat / 0 L 14-NC , 10 ✓
Signature: -LA-6 Effective Date: eC � a / 6a 3
"I 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."
Mail, fax or email WPCSOCC, 1619 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC27699-1618
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
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax:[phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016