WQCS00213_ORC Designation Form_20230731

NC Dept of Fnvironmciital Qual
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201 JUL 3 1
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Facility Name: STANTONSBURG COLLECTION SYSTEM
Permit# WQ& Aq�egtolialOffice
Facility Type: CS Facility Grade: I St1BMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Brian Hawiey
Email Address: bhawle townofsta onsburn.com
Permittee Signature: / �--✓ �_ __
ORC
Operator in Responsible Charge,
Full Name:
Email Address:
Certificate Type: Select Certificate Grade: I
Date:
Work Phone:
Certificate #:
Signature: Effective Date:
"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
Full Name: Jeffery Devon Hill Jr. Work Phone: [phone]
Certificate Type:. CS . _ Certificate Grade: I� _. Certificate #- 1004520
. ?lZ 7�
Signature: Effective bate Z�
*deby
I o ree to my designation as a Back p Operator in Responsible Charge for the facility noted. I understand and will
rules and regulations pertaining to a 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."
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
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 ORIGINAL to: WPCSOCC,1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: [phone] [e-mail]
Mail or fax a COPY to: Raleigh-3800 Barrett Dr.,Raleigh, NC 276091 FAX: [phone] PH: 919-791-4200
Revised V2018