NC0025453_ORC Designation Form_20240119

Water Pollution Control System OPERATOR IN RESPONSIBLE CHAhd1V(QK):DiaMgrwtiio� fpr.T
NCAC 15A 8G .0201
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Facility Name: Sam's Branch WRF
Facility Type/Classification: WW a Facility Grade: IV a
Permittee Owner/Officer Name: James Blalock
Email Address: [e-mail]
Permittee S
Full Name: David Franklin White
JAN 2 5 2024
PeTI t 25453
t{:r� l�tl-k)gionaf o' ince
SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
ORC
Operator in Responsible Charge
Date:
Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW__ 0 Certificate Grade: IV 0 Certificate #: 1011005
Signature: A«G.L Effective Date: / T 11
`7� 2u2c1
certify that l agree to my designation as the Operator In Responsible Charge for the facility noted. ! 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 WPC50CC"
Full Name:
Salvador Valdiviezo Jr.
Certificate Type: WW _ 0
Backup ORC
rade:
IV 0
Work Phone: [phone]
Certificate M 1009190
Signature: ���� 1� � _.=T� Effective Date: /ZI,7ZZe 2 X
I certify that I agree to my designation as the Operator in Responsible Charge f 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 WPC50CC"
Backup ORC
Full Name: James Warren Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 7149
Signature: �Effective Date: / 17 262y
"! certify that I agree to m des' ation as the Operator in Responsible Charge for the facility noted. i understand and will abide by the rules an regulations
pertaining to the respons Ries 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]
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: Raleigh_3800 Barrett Dr.,Raleigh`NC 27609 1 FAX: [phone] I PHT919-791-4200
Use the 2nd page only if you need to Ist additional Backups.
Revised 1112023

Facility Name: Sam's Branch WRY'
Full Name: Brian C. Gay
Certificate Type: WW 0
Permit M
Backup ORC
Certificate Grade: IV
0
Work Phone:
Certificate #:
25453
t il
[phone]
9187
Signature: /Vzj�57c,J1/ Effective Date: 0 I 1 I$ 1 7-0 Z.Ll
"l certify that ! agree to my designation as the Operator in Responsr a Charge for the facility noted. ! 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: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate M
Signature: _ _ _ Effective Date:
"i certify that ! agree to my designation as the 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 NC,4C 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate M
Signature: Effective Date:
"! certify that ! agree to my designation as the Operator in Responsible Charge for the facility noted. / 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:
Certificate Type: Select Certificate Grade: Select
Work Phone:
Certificate #•
Signature: Effective Date:
"1 certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. ! 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"
Revised 11/2023