NC0036935_ORC Designation Form_20240208

Water Pollution Control System OPERATOR iN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: PINE MOUNTAIN POA
Facility Type/Classification: WW
Permittee Owner/Officer Name: Edith
Email Address: Q I h2
Permit # NCO036935
Facility Grade: 11 SUBMIT A SEPARATE FORM FOR EACH CtASS1FiCAT1ON
President Pine Mountain POA
Permittee Signature: Date: 2-/ 1Z C
ORC;
Operaic� -in Respd tsibfe Charge
Full Name: Ronald Epperson work Phone: [phone]
Email Address: ip nemoountainpoa gmaii.com
Certificate Type: WW Certificate Grade: 1i Certificate #: 1014592
Signature: " Effective Date:/ I c}-
`9 certify that l agree to my designation as he ero r 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 i 15A NCAC 08G _0204 and faffing to do so can result in Disciplinary Actions by the wpCSOCC-
Full Name: Kellie Hedrick Work Phone: [phone]
Certificate Type: WW Certificate Grade: l) Certificate #: 1005640
Signature: Effective Date: 4 i
3.4
-1 certify that l agree to my "i on he Operator in R sible Charge for the facility noted. l understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set rth in 15A NCAC 08G .0204 and failing to da sa can result in Disciplinary Actions by the wpcsOCC-
09'
:' i$a€�clCu0, QRC
Full Name: Kimberly Holt Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV
Certificate #: 993802
Signature:
Effective Date:
"t certify that l agree to 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 WPCSOCC"
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AND Re i
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Q g onal Office (send to your contact or find emails here: www.deq.nc.gov/about/c DI
or fax using this drop down list: /regional -offices
Asheville-2090 US H 70, Asheville, NC 28778 ; FAX: [phone] k ,. 6,2-8-2 0o 8 psi
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