WQ0007569_ORC Designation Form_20240501 (2)

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Perrnittee Owner/Officer Name:
Email Address: +on.l • k
NCAC 15A SG .0201
Press TAB to enter information
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Digitally signed by Tony Konsul
NM:—Dib" TSttKoOetioc". 0-1
Aola WaterryCN
, E=ony.eopsu@arolnawaterservenucomTony KonsLaonKnoInmlheahorfhisdocument
Date: 0 Di/202 y
Permittee Signature: Date:zoza.os.1o:os:36oabo'
Foxit PDF Editor, Version: 13.0.E
Facility Name: gCAAA4W;ne Permit# W0� 0flD1$'&Oj
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: W W 11
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: SO MV4.1 66-Y, Work Phone: ZS2_-80$ - 76 76
Certificate Type: W W Certificate Grade: I i Certificate #: / o I I Z q&
Email Address: Satm,el CoK�% Caro i,ngWa�erStrv►'ce nc, csr�
Signature:
Effective Date: O S&Zz*2y
"I certify that 1 agree of my designation as the 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: Ax+^ ,on.l Fu'`�Te i I Work Phone: 312 - 96S- 372?
Certificate Type: fn Q Certificate Grade: IV Certificate M
Email Address: per- Vcw,�.-K{rGi!@ carol;,,Awoder5ery,c.entrcof,
Signature- Effective Date: O s 14l l-20 2 Y
"I certify that I agree to my desip05n 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, Raleigh, NC 27699-1613
ORIGINALto: Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27339
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 29405-2845
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: 919-S71-4718
Phone: [phone]
Revised 1112020

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: L"arni ino, I, a+&- Seryt`ce f Inc... CrF IV 4- /TLI", Kan3_�
Email Address: n r kenSvl Q Caro(,ngw^irrS�f'v:ccn�,Ca.►.
Digitally' ony onsu
�DN OU-"Director, State Operations", O-Carolina Water Service.
Tony Ko n S R onY Konsul E=Tony this document
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n: am the author of this document
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Permittee Signature; FooxitPF4Editor Veroon5000 13Date.
Facility Name: «%ary ��� l�"'le S Permit # IV( -
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: W I,J 11
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Sotm f( Cot Work Phone: ZSZ, S0d°- i6'76
Certificate Type: W W Certificate Grade:
Email Address: Samuel-Go,c Q C44Cc61ina WX+6e SfrVicl
11 Certificate #: 100716
Signature: , — Effective Date: 45-f6r/Zoz y
"1 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 03G .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: %1nA1r~a j Fi+(,cl( Work Phone: 312, QGS- 372b'
Certificate Type: w W
Certificate Grade: 1 V Certificate #: /o/ 3 2 G G
Email Address: a(r1-}-"rq . `Pj+rt!! e Ce ro /; n4 wAier rert,,ce ? c , c&i
Signature: Effective Date: d,T/ot t✓2p7_y
`7 certify that 1 agree to my esignation 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
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301
Swannanoa, NC 28778 Fayetteville, NC 23301-5043 Mooresville, NC 23115
Fax:[phone] Fax:[phone] Fax:[phone]
Phone: [phone] Phone: [phone] Phone- 704-663-1699
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 23405-2345
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9300
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 1 V2020