WQ0011655_Operator Designation Form (WPCSOCC)_20231229

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: G. Dwayne Jones
Mailing Address: PO Box 1698
city: Kinston
Email Address: dwgne.jones,6�bcouting.org
Signature:
Phone: [phone]
State: NC zip: 28503
Date: 12-1' —0��
Facility Name: East Carolina Council, Inc.Wamp Boddie Permit # WQ0011655
County: Beaufort
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
SI El
Facility Grade:
I 0
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Benjamin Davis Work Phone: [phone]
Certificate Type: SI 0 Certificate Grade: 11 0 Certificate #: 18551
Email Address: [e-mail]
Signature: Effective Date: 1Z.(r40= Z�
"I certify that/ agree to my esignation 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: Louis Delozier Work Phone: [phone]
Certificate Type: SI
0 Certificate Grade: I 0 Certificate #:29106
Email Address: [e-mail]
Signature:
--7
Effective Date: 1'- - ( 6 - 2-3
"I certify that/ 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."
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: 91G-350-2004
Phone: [phone]
Mooresville
Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115
Fax: [phone]
ax: 919-5 1 4718 �609
Phone:[phone]
Phone:[phone]
DEC 2 9 2023
Winston-Salem
45 W. Hanes Mall Rd.
Water Quality
Winston-Salem, NC 274f6blonal Operations Section
Fax: [phone]
Washington Regional Office
Phone: [phone]
Revised 412016