WQ0004115_ORC Designation Form_20240129

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCQ
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Craig Galloway
Mailing Address: 5 Pine Shadow Drive
City: Hendersonville State: NC
Email Address: or gMchg"nrVls.com
Signature: X - II- r tlwh4k_#
Facility Name: Champion Hills
County: Henderson
77p 4—
Phone: [phone]
zip: 28739
Date: i Z'
Permit # W00004115
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW _
Facility Grade: WI
OPERATOR IN RESPONSIBLE CHARGE (ORC) _
Print Full Name: Danielle Ann Hunter Work Phone: [phone]
Certificate Type. WW
Certificate Grade: 11
Email Address: [e-mail],,
Signature:
Certificate #: 23477
Effective Date: f II I/
"i certify that l 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Robert P. Barr Work Phone: [phone]
Certificate Type: WW Certificate Grade: I!! _ Certificate #: 8928
Email Address: [e-mail]
Signature: IjyvwEffective Date: 1 I13L 1 2-
"l certify that ! agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l 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
Raleigh
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Mooresville, NC 28115
Raleigh, NC 27609
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone] Revised 412016

WPCSOCC Operator Designation Form (continued)
Facility Name: Champion Hills _
C
Print Full Name: Kenneth Jason Rummel
Permit #: WQ0004115
BACKUP ORC
Work Phone: [phone]
Page 2
Certificate Type: WW Certificate Grade: III Certificate #:1010299
Email Address: [e-mail]
Signature: Effective Date:
"I certify that 1 agree to my designate 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 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."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Work Phone:
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 can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
I
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate M
Signature: Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Chorge 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 can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name:
Certificate Type: Select Certificate Grade: Select
Email Address:
Work Phone:
Certificate #:
Signature: _ Effective Date:
"i certify that I agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
Revised 412016