WQ0003396_ORC Designation Form_20230214

OPERATOR IN RESPONSIBLE CHARGE
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
'7 certify that 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 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name: We,,hV64 L4/iV- ,
Certificate Type: SI
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter
NC D*W� ihme:
Mailing Address:
FEB 14 2023 City ORCo( State:
Email Address: ; GNi
Raleigh Regional Offiftnature:
Facility Name: A(td u 1u0(
County:
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Phone:
Zip:
Date: Z-7-)-?
Permit # �Jv Oi
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: ISI
Facility Grade: II Grad
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
BACKUP ORC
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Certificate Grade: II
Email Address: C-�rr �„, r ;n (PAraNcp. C
Work Phone: gig - 730 - 507
Certificate #: 1011n(,
Signature: Effective Date: 1/ 19 12023
"1 certify that 1 agree to my designation as a ack-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 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 SG. 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 Mail Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
RBWsed 4,2016