NC0026271_ORC Designation Form_20240110

Jan 04 2024 3:03pm TaylorsvilleWWTP 8286322079 p.1
Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Taylorsville WWTP Permit# NUUucocr I
Facility Type/Classification: WWQ Facility Grade: III F71 SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Town of
Email Address: sbe1963
Permittee Signature:
Full Name
Email Address:
Certificate Type: Select
Steve Brian Eades
ORC
Operator in Responsible Charge
Certificate Grade: Select
Date: / / ZO-2-Y
Work Phone:
Certificate #:
Effective Date:
Signature:
"f certify that) agree to my designation as the Operator in Responsible Charge forthe facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as setforth in 15A NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC'
Backup ORC
Full Name: Dustin Joseph Dillard Work Phone: [phone]
Certificate Grade: III El Certificate #: 1009437
Certificate Type: WW er—
Signature: / 7r Effective Date: //,;! 2- -
"! certify that agree to my designation as the Operator in Responsible Chargefor thefacility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as setforth in 15A NCAC 08G.0204 and falfing to do so can result in Disciplinary Actions by theWPC90CC"
Backup ORC
Work Phone:
Full Name:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature: Effective Date:
"I certify that / 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 ORCas setforth in 15A NCACOSG.0204 andfailing to do so Can result in Disciplinary Actions by the WPCSOCC"
Email this form to: [e-mail]
AND
Send to your DEQ Regional Office (send to your contact or find emails here: www.,deq.nc.gov/about/contact/regional offices. \
or fax using this drop down list: Choose DWR Regional Office that has coverage of this facility.�/hoOrtE_CVKLE Q£FsiotytL. d/'f/cE j
Use the 2nd page only if you need to list additional Backups.
Revised 1112023