WQ0011431_ORC Designation Form_20240601

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Permittee Owner/Officer Name:
Email Address
NCAC 15A 8G .0201
Press TAB to enter information
Town of Cleveland
[e-mail]
42 v�
Permittee Signature:
Date: fib /Z
Facility Name: Town of Cleveland WWTP
Permit # WQ0011431
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: LA
Facility Grade: I
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Robert P. Willcox, Jr. Work Phone: [phone]
Certificate Type: LA Certificate Grade: Select Certificate #: 13285
Email Address: rob@willcoxmab/esooil.com
Signature: �/� Effective Date: 6/1/24
"/ certify that / agree to my designation as the 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."
BACKUP ORC
Print Full Name: Martin E. Mabe Work Phone:
336-312-1396
Certificate Type: LA Certificate Grade: Select Certificate #:
22753
Email Address: [e-mail]
Signature: AEffective Date:
6/1/24
"1 certify that / agree to my designation as a Back-up 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax:[phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
Raleigh
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115
Raleigh, NC 27609
Fax:[phone] Fax:[phone] Fax:[phone]
Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mill Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Fax: [phone] Phone:
Phone: [phone] Phone: [phone]
Revised 512019