WQ0004115_ORC Designation Form_20240123

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Perm ittee Owner/Officer Name: Craig Galloway
Facility Name
County:
Mailing Address: 5 Pine Shadow Drive
City: Hendersonville State
Email Address: [e-mail]
Signature:
Champion Hills
Henderson
SIR
Phone: [phone]
Zip: 28739
Date:
Permit # WQ0004115
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name. Danielle Ann Hunter Work Phone: [phone]
Certificate Type: WW Certificate Grade: 11 Certificate #: 23477
Email Address: d nter@rpbsdyste/m�s.com
Signature: {, lA.. Effective Date:
certify that 1 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 asset 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
Print Full Name: Robert P. Barr Work Phone: [phone]
Certificate Type: WW Certificate Grade: III Certificate #: 8928
Email Address: [e-mail]
Signature: Effective Date: i 1T f Z
"I certify that I 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 WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL. to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone:[phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax; 336-776-9797
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: Champion Hills Permit #: WQ0004115
BACKUP ORC
Print Full Name: Kenneth Jason Rummel Work Phone:[phone]
Certificate Type: WW
Certificate Grade: III
Email Address: [e-mail]
Signature:
Certificate #:1010299
Effective Date: f -/ �/
"1 certify that I agree to my designati6WVas a Bock -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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 understond and will abide by
the rules and regulations pertaining to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that I 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 con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"I certify that/ 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 falling to do so con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 412016