WQ0015162_ORC Designation Form_20240311 (2)

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Farm
Facility Name: dr /vim Permit# WA00/SI62L
Facility Type/Classification: Ww Facility Grade: Select SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
!✓ ,
Permittee Owner/Officer Name: (fly f A , t� ,-c8 y
Email Address: 01"F Of//t'C. -s O' c2rJ/I't-A ae"
Permittee Signature: (/�.,i/o/ioii.,Y... -. Date: ✓ ^ %/ Y
ORC
Full Name: ��Zoer^cam /cl�wo�fv Work Phone: (s st) 0'Ce/9-W/'J
Email Address: t� rJurYS�Hae,a. �co •+
Certificate Type: Select Certificate Grade: Select Certificate #: /00 (,3%Z
ww / 1, Z
Signature: __�� If. �� Effective Date: 3 -S-,2o tt/
-1 certify that l ogree to my designation as the Opemt m Responsible Charge for the focilitynoted. 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 DisciplinoryActions by the WPCSOCC'
(' � , (`'� Backup ORC
Full Name: S��S'L�-CU �'"' � Work Phone:
Certificate Type: Select
I ,Certificate Grade: t Certificate #: qs Li 31-)
Signature: Yy�) t( ,,v> Effective Date:
•1 certify that I agree to mydesi notion as the operator In Responsible Charge for the focility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC m setforth in 15A NCAC 08G.a204 and failing to do so can result in Disciplinary Actions by the WPCSOCC`
Full Name:
Certificate Type: Select
Signature:
Backup ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
-1 certify that I agree to my designation as the Operator in Responsible Chorgefor the facility noted. 1 understand and will abide by the rules and regulations
pertaining to the responsibilities of the ORC as set forth in ISA NC4COgG.0204 and failing to do so con 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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only If you need to list additional Backups.
Revised 02l2024