WQ0022870_ORC Designation Form_20230324

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION PWIW 7talQuality
Facility Name: Chapel Ridge
County: Chatham T
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Aqua North Carolina/ Robert Krueger
Mailing Address: 202 Mackenan Ct —
City. Cary T State: NC
Email Address: RDKruege america.com
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MAR 2 4 ?623
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Zip: 27511
Signature:f T --
Date:
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Permit # WG %J%Je- 70
_1623
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
facilityType: WW
Facility Grade:
- OPERATOR IN RESPONSIBLE CHE {ORC)
Work Phone: [phone]
Print Full Name: Eric L Riggins
Certificate Type: WW .
Certificate Grade: II Certificate #: 1000135
Email Address: E s@aqua m 1ca.com T
q -- c -
Effective Date: 3 Z-3
Signature:
"I certify that 1 agree to my designation as the O erator 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 Control System Operators Certification Commission."
�T- --- -- BACKUP,ORC_=. _
Print Full Name: Roy D Lyons Wark Phone: [phone]
_ Certificate Grade: IV: Certificate #: 1005944
_certificate Type: WW - . .
Email Address:, RDLyons@aqd merica.com ---
Signature: Effective Date:3 7 ' _—
"I certify that I agree to my designation s 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 Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, F=.919-715-2726 Email: [e-mail]
QRIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
Fayetteville Mooresville Raleigh
a COPY to: 2090 US Hwy 70 225 Green SU, 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],40 Fax: [phone]
Phone:[phone] Phone:[phone] Phone:[phone] Phone:[phone]
x 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 77105
Fax:[phone]-Fax:[phone] Fax:[phone]
Phone•')57-946-6481 Phone: [phone] Phone: [phone] Revised 4=f6