NC0023884_ORC Designation Form_20240129

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: City of Salisbury WWTP Permit # NCO023884
Facility Type/Classification: WWQ
Permittee Owner/Officer Name: Cityof
Email Address: [e-mail]
Facility Grade: IV El SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Signature: tw., /ct4�—
Full Name: Charles Edward Wood, Jr.
/ Jim Behmer, Utilities Director
ORC
Operator in Responsible Charge
Date:
Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 990826
Signature: A ur,� Effective Date: OIZQ-
"I certify that I 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 WPCSOCC"
Full Name:
Brian David waller
Backup ORC
Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 1009749
Signature: �_ �� `✓� _ Effective Date: O 1 /� 1 I2.C%2-4-
"I certify that l 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 WPCSOCC"
Backup ORC
Full Name: Andrew Travis Moysan Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV F-1 Certificate it: 1009757
Signature: / �� %.1�-1— Effective Date: UI /DI / 72x24
"I certify that I agree to my desighah n as the Operator in Responsibl�or 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 WPCSOCC"
Email this form to: [e-mail]
Send to your DEQ Regional Office (send to your contact or find emaiIs here: www.deq.nc.gov/about/contact/regional-offices
or fax using this drop down list:!, Mooresville-610 E. Center Ave., Suite 301, Mooresville, NC 28115 1 FAX: [phone] PH: 704-6f
Use the 2nd page only if you need to list additional Backups.
Revised 112023