WQ0029821_ORC Designation Form_20240118

Water Pollution Control SVstem OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Fora
NCAC iSA SG .O201
TAR to Navigate Form
Facility Name: BOGU WATCH W1JVTP Permit # WQ0029821
Facility Type/Classification: WW Facility Grade: iii StRMITASEPARATE FORM FOR EAC14CtASSIF1CA7"ION
Per€rtittee Owner/Officer Marne: Joel M11139US
Email Address:[e-mail]
Permittee Signature;
Full Name: Raymond Braxton Mork Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW Certificate Grade: IV Certificate #: 999895
Signature: Effective Llate: ! — / 2' t
certify that I agree to my resignation as the Operator in Responsible Charge for the facility noted. I understand and w0l abide by the rules and regulations pertaining
to the reslaansskiiltlrs of the ORC as set fortis in 15A NCAC OUG W04 and foiling to do" con result in flrsdplinoty Actions by the WPCSOCC"
Full Marne: Michael Cowell Work Phone:, [phone]
Certificate Type: WW Certificate Grade: it Certificate #: 1007662
Signature: Effective bate:
certify that 1 agree to my esignation os the Operator in Rcspanslbhe Charge far the facility noted. ! understand and will abide by the rules and regulations pertaining
to the respansibill€fes of the ORC as set forth in 25A NCAC 086.OZI&R and falling to do so con result in Disciphouty factions by the WKSOCC"
Full Name, Work Phone -
Certificate Type: Select Certificate Grade; Select Certificate fit:
Signature:
Effective Bate:
"°I certify that I agree to mydesignotion as the Operator in Pesponsibfe Charge for the facility noted. 1 understand and will abide by the rules and regulations
pertaining to the responsilWities of the ORC es set forth in 15A NCAC 03G,0204 and failing to do so con result in DisdplinaryActiicm by the WPaoW
Email this form to: [e-mail]
AND
Send to your DEQ Regional Office {send to your contact or find emalls here: www.deq.nc,gov/about/contact/regional-offices
Choc3se DWR Re lanai Off.ice that has covers a of �,..._
or fax using this drop dtarian list.: � grc ibis facility.
Use the 2nd page only it you heed io Mt o dditional Backups
Revised 11/2023