WQ0015162_ORC Designation Form_20240311

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE(ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: � `� G''� /vim Permit# `A)q O>,S ! & L
Facility Type/Classification: Select Facility Grade: Select SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
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Permittee Owner/Officer Name: G/�i /, lJ l!i-Q-�s 4 ✓ "f Q�C�
Email Address: C�r F L/�l���c«t S 6` �Lr1 it✓t�. Cw:`+�t
Permittee Signature: ,�i,,,,,, Date:
ORC ��/ //
Full Name: ��,�kZ /nff I Work Phone:(;,fi)OV119-W/'7
Email Address: lV + h f7S �^��• �ecn'
Certificate Type: Se� Certificate Grade: SeieCt Certificate#: I UO G,3LO-
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Signature: Effective Date: 3-e-.2oa-t(
"I certify that I agree to my d ignation as the Operat m 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"
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Backup ORC
Work Phone: a�a- 6�0-
Full Name: ��(S
Certificate Type: Certificate Grade:_Select Certificate#:
Signature: Effective Date: `t
"I certify that I 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: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"I certify that 1 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"
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:iChoose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 0212024