WQ0031246_ORC Designation Form_20240328

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: GeO�ov I4 I ( . ►Fr estci e v.: -
Mailing Address: PO i30K Phone:
City: E4i2v4VY-) State: tJL Zip: ;�-7937_-0572
EmailAddress: a�C�JzfSc�t✓L(�OGL.Gor+�
Signature: X Date: o Z I
Facility Name: 'P.JztrSduy'A W 4JTP Permit# 00 3 1 a 4 fp
County:
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
ISelect
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Facility Grade:
ISelect
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OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Work Phone: ZS2- ZRZ- 32Z
Certificate Type: Select W W - 1 Certificate Grade: Select ( Certificate #: to l 3 (0 3 4
Email Address: %I%ay,atI.e.1 Q)_ 0.el, toCjL,v-L+
Signature:
Effective Date: + - I - dui
"1 certify that I agree pd'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: 3 G weg-� CY6lN vv� e r- Work Phone: 59 0 -ZED
Certificate Type: Select la LA-} - ( Certificate Grade: Select Certificate #: 10 t i4 O$ 44
Email Address: (,c r-" M e r 6) az� wa, M e-4-
Signature:
Effective Date: 4-1 - Z
"I certify that I ogre�ortft y Resignation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC,1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINALto: Raleigh, NC27699-1618
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] Revised412016

WPCSOCC Operator Designation Form (continued)
Page 2
Facility Name: �1Ve1'SauvJ WWiP
Permit #: W ck 00 3 I Z4 (P
BACKUP ORC
Print Full Name: 1��� e� R1, ales Work Phone: Ih 9 --1 S i - ZI '}
Certificate Type: Select W W •- y Certificate Grade: Select y Certificate #: I O O (, L} I
Email Address: prhodrs a)^0.qu:a,v�e
Signature:
Effective Date: 4-1- Z4
"I certify that I agree td /ny desigri6tion 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."
BACKUP ORC
Print Full Name: %ev e" j3o-v r.1 Work Phone: q, t of - `i2-7
Certificate Type: Select Uj LLi - Lf
Email Address:
Signature:
Certificate Grade: Select kI
Certificate #: 1 o O ;3(nob S
"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."
1 BACKUPORC
Print Full Name: Mtako�1 ciyWork Phone: 2SZ-Z`iZ-16(o
Certificate Type: Select W W - 3 Certificate Grade: Select
Email Address: rn c1&y 4-7A, r j &6, Wa. v<-e+
Signature:
J
Certificate #: typ •5 Zp t
Effective Date: +- t - Z 4
"I certify that 1 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."
Print Full Name:
Certificate Type: Select W w -
Email Address: 0_4 wa+&v�
Signature:
BACKUP ORC
Certificate Grade: Select f
-5&.ejr(5 t3 otvr L�L I -LD rvI
Work Phone: ZS'Z-Z9z-g�oU
Certificate #: 9 9 'Z rl Z Z
Effective Date: 4--(- Zy
"1 certify that I agree to my designation as d Bdck-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 .0104 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
7
Revised 412016