WQCS00293_CEI Letter and Report 2024_20240718

Docusign Envelope ID:C90047FA-7973-4C80-A486-67484CA08CFB
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MICHAELS. REGAN
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LINDA CULPEPPER NORTH CAROL1NA
Uir-�crar Environmental Quality
July 18, 2024
Ms. Shannon Becker
Aqua North Carolina Inc.
Governor's Club Collection System
202 Mackenan Drive
Cary, NC 27511
Subject: Compliance Evaluation Inspection
Govenor's Club Collection System
WWCS Permit WQCS00293
Chatham County
Dear Ms. Becker:
On July 10, 2024, Donald Smith, and Myles Parker from the NC Division of Water Resources -
Raleigh Regional Office (RRO) conducted an inspection of the Governor's Club wastewater
collection system to evaluate compliance with the operation and maintenance of the subject
wastewater collection system permit. The cooperation and assistance of Wesley Bishop, Ashely
Kilinger, and Roy Lyons during the inspection were greatly appreciated.
Records indicate the wastewater collection system consists of approximately 4,023 feet of
gravity sewer, approximately 21.4 miles of force main, more than 780 simplex pump stations, 8
duplex pump stations, and no high priority sewer lines.
The subject permit is effective from May 24, 2018, until January 31, 2025, and is subject to
specific conditions and limitations. The items below show what conditions were noted during
the inspection:
1. Reported Sanitary Sewer Overflows. During the period of January 1, 2022, and July 9,
2024, there were 3 SSOs from the Governor's Club collection system with a combined
estimated volume of 2,750 gallons, of which 2,650 gallons reached surface water. The
SSOs during this period, resulted in this office issuing the following notices. No fish kills
were reported because of the SSO events.
Reported Sanitary Sewer Overflows Notice Issued by Division of Water Resources-RRO
April 7,2022 [Notice of Violation
October 26,2023 Notice of Violation
April 24,2024 Notice of Deficiency
D���� Not th CuroUna Dcp:wtmesu of Cnvironmrnt:d Quali?} Uivi�ion of`,'�'atcr Rcsuurcrs
1 —' Raleigh Regional office I :)doo Barren Drive I Raldoh.North Carolina 27(A)ct

Docusign Envelope ID C90047FA-79734C80-A466-67484CA08CFB
Permittee,WQCS00293
July 18,2024
2. Fats, Oils and Grease Program. Aqua North Carolina Incorporated, hereinafter referred
to as PERMITTEE, has developed and implements an educational fats, oils and grease
program that includes at least bi-annual distribution of educational material targeted at
both residential and non-residential users. The PERMITTEE has also developed and
implements an enforceable FOG program for non-residential users.
3. Capital Improvement Plan. The PERMITTEE establishes and manages funding for
wastewater collection system infrastructure maintenance and repair. Funds are
determined and based on the regulatory oversight of the NC Utilities Commission.
4. Contingency Plan for Pump Failure. The PERMITTEE maintains a contingency plan
for collection system and pump failure for the simplex and duplex lift stations.
Contracted services are available to assist with pumping and hauling if needed. Some
pump stations (ie: Clubhouse PS) has bypass pump connection for mobile pump
connection. Each duplex lift station has generator connections for emergency backup
power. Three mobile generators are available to serve the 8 lift stations.
5. Pump Stations Inspected. The following pump stations were visited and inspected.
a) Walker Wood Lift Station
• (2) submersible pumps
• At the time of the inspection, the wet well and float controls were clean and clear
of excessive grease and debris.
• High-Level Alarm (audible/visual) was tested and was functional during the
inspection.
• Omni-site telemetry was operational and high-level alarm testing was received
through a smart phone by text and a phone call.
• Lift station will facilitate the connection of a portable generator.
• An upstream gravity line manhole was inspected and found to be free of blockage
and greasedebris accumulation.
b) East Church Lift Station
• (2) submersible pumps
6 At the time of the inspection, the wet well and float controls were clean and clear
of excessive grease and debris.
• High-Level Alarm (audible.'visual) was tested and was functional during the
inspection.
• Omni-site telemetry was operational and high-level alarm testing was received
through a smart phone by text and a phone call.
• Lift station will facilitate the connection of a portable generator.
c) Club House Lift Station
• (2) submersible pumps
• At the time of the inspection, the wet well and float controls were clean and clear
of excessive grease and debris.
Page 2 of 5

Docusign Envelope ID:C90047FA-7973-4C80-A486-67484CA08CFB
Pennittee,WQCS00293
July 19,2024
• High-Level Alarm (audible.'visual) was tested and was functional during the
inspection.
• Omni-site telemetry was operational and high-level alarm testing was received
through a smart phone by text and a phone call.
• Lift station will facilitate the connection of a portable generator.
• Lift station has a by-pass pumping connection for a portable pump.
d) South Entrance Lift Station
• (2) submersible pumps
• At the time of the inspection, the wet well and float controls were clean and clear
of excessive grease and debris.
• High-Level Alarm (audible.'visual) was tested and was functional during the
inspection.
• Omni-site telemetry was operational and high-level alarm testing was received
through a smart phone by text and a phone call.
• Lift station will facilitate the connection of a portable generator.
e) 10424 Stone Road Simplex Lift Station
• (1) submersible grinder pumps
• Wet-well and control cabinet are located beside the house and was accessible.
• Simplex system included a high level audible-visual alann. PERMITTEE is
responsible for maintenance and repair of simplex pump systems.
• Homeowners have appropriate contact information to report system problems or
alarm conditions.
f) Force Main Air Release Valve (ARV)— Morehead Drive
• ARV was inspected and found to be operational and the isolation valve in the
open position. No evidence of leaks was found during the inspection.
6. Pump Station Signage. Each pump station has signage clearly and conspicuously posted
that identifies the pump station, provides an emergency 24-hour contact telephone
number(s), and provides instructions for notification if the visual alarm illuminates and:'or
the audible alarm sounds, or if an emergency is apparent.
7. Pump Station Restricted Access. The pump station sites, equipment and components
were observed to have restricted access. All wet-well and control panels were pad locked
and secured.
8. Pump Stations Automatic Polling Feature. The pump stations are equipped with Omni-
Site telemetry'SCADA that allow the PERMITTEE routine contact with the pump station
from an electronic device(laptop phone) to check the operational status of the
communication system. During the inspection, the Omni-Site telcmetryfSCADA
acknowledged the alarms when the high-water float was activated.
Page 3 of 5

Docusign Envelope ID:C90047FA-7973-4C80-A4B6-67484CA08CFB
Permittee,WQCS00293
July 18,2024
9. Pump Station High Water Alarms. The pump stations are equipped with audible and
visual high water alarms. During the inspection, these alarms functioned properly. The
operator received the high-water alarm remotely to their smart phone.
10. Pump Station Inspection Program. The PERMITTEE has developed and implements a
weekly routine inspection of each pump station that includes the following maintenance
activities: cleaning and removing debris from the pump station area and wet well;
inspecting all valves; inspecting pumps and other mechanical equipment; and verifying
the proper operation of the alarms, telemetry system and auxiliary equipment. The
inspector reviewed the inspection logs of the pump stations visited and observed adequate
entries of the date and time of the operator's inspection, observations made, and any
maintenance, repairs, or corrective actions taken. Service Link work order system is
utilized for managing and recording system operation and maintenance tasks.
11. Designated Operators. The PERMITTEE wastewater collection system is classified as
a Class-2 system. The Division of Water Resources does not currently have a designated
certified Operator in Responsible Charge (ORC) listed for the Governor's Club
wastewater collection system. Seven (7)back-up ORCs are on record that include Larry
Wayne Alford, Alan Drew Bailey, Steven Glen Johnson, Kenneth Leslie Langston,
Calvin Maurice Leach, Christopher A. McDonald, and Aldon Ratliff. In accordance with
Section 11 (L)of your permit, "Upon classification of the collection st�steni by the Water
Polhition Control System Operators Certification Commission (WPCSOCQ. the
Pernittee shall designate and employ a certff ed operator to be in responsible charge
(ORC) and one or more certified operator(s) to be back-tip ORC(s)of the facilities in
accordance with 15A NCAC 8G.0204".
Provide the NC Division of Water Resources a completed ORC designation form
(attached) naming a properly certified operator as ORC for the Governor's Club
Wastewater Collection System and your permit. The Governor's Club collection
system is non-compliant without a properly designated ORC.
12. Cleaning Sewer Lines.The PERMITTEE has developed and implements a program for
cleaning the sewer lines. As required by Section 11.8 of the subject permit, at least 100'o
of the wastewater collection system should be cleaned each year. Preventative cleaning
is not required for sewer lines less than five years old, unless an inspection reveals the
need for cleaning. Mr. Bishop provided a record during the inspection that
approximately 700 feet or 17-percent of sewer line were cleaned in calendar year 2023.
13. Spill Response Action Plan. The PERMITTEE has developed and maintains a Spill
Response Action Plan that includes 24-hour contact numbers, response time (within 60
minutes), equipment list and spare parts inventory, access to cleaning equipment, access
to construction crews, sources of emergency funds, site sanitation and cleanup materials,
and post-SSO assessment. The Pennittee utilizes contracted services to assist in sewer
spill cleanup and major infrastructure repair.
14. SSO Records. The PERMITTEE has maintained adequate records pertaining to SSOs
and sewer complaints for the three-year period ending May 2024. The last reportable
SSO occurred on April 24, 2024. According to Mr. Bishop, no non-reportable SSOs
Page 4 of 5

Docusign Envelope ID:C90047FA-7973-4C80-A4B6-67484CA08CFB
Permittee, WQCS00293
July 18,2024
occurred for the last three years. The inspector reminded Mr. Bishop that all SSOs
whether reportable on non-reportable should be documented and recorded as required in
Section III (2.)of the permit.
15. Comprehensive Sewer Map. The PERMITTEE maintains an up-to-date comprehensive
GIS based map of its sewer collection system. The map includes pipe size, pipe material,
pipe location, Flow direction, approximate pipe age, number of active service taps, and
each pump station identification, location and capacity.
16. Inspection of High Priority Lines. The PERMITTEE does not list in the permit or have
high priority lines associated with their system. According to Mr. Bishop, the system
does not include any aerial lines, siphons, or pipelines that run perpendicular to streams
that are or may be affected by stream erosion at the time of the inspection.
Please provide this office with a written response to items 11 above no later than
September 30,2024. The overall condition of the collection system was compliant with the
wastewater collection system permit requirements observed on the day of the inspection;
however, the system is non-compliant without a designated ORC. Please take note that your
collection system permit expires January 31, 2025. Section VI (6.) of your permit requires "The
permittee shall file an application for renewal of this permit at least six months prior to the
expiration date...". If you have questions or comments about this inspection or the requirements
to take corrective action if applicable, please contact Donald Smith at 919-791-4234.
Sincerely,
[U
DacuSigned by
a v -SS& f. hattn.tcd
82916E6AS32144F
Vanessa E. Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Attachment(s): Collection System Inspection Report
ORC Designation Form
Cc: Laserfiche
Page 5 of 5

Docusign Envelope ID:C90047FA-79734C80-A4B6-67484CAOBCFB
Compliance Inspection Report
Permit:WOCS00293 Effective: 05,`24,'18 Expiration: 01/31/25 Owner: Aqua North Carolina Inc
SOC: Effective: Expiration: Facility: Govenors Club Collection System
County: Chatham PO Box 2615
Region: Raleigh
Chapel Hill NC 27515
Contact Person:Amanda Berger Title: Compliance Manager Phone:[phone]
Directions to Facility:
System Classifications: CS2,
Primary ORC: Roy David Lyons Certification: 1005505 Phone:[phone]
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
W00000088 Aqua North Carolina Inc-Governors Club WWTP
Inspection Date: C7/10/2024 Entry Time 09:1OAM Exit Time: 12 OOPM
Primary Inspector:Donald Smith ozusianedby; 7/18/2024 Phone: [phone]
Secondary Inspector(s): [V�"U
5"
2ED5247FAB47A
Myles Parker Docusignedby: 7/19/2024 f at�cr t yl
Reason for Inspection: Routine 7' Inspection Type: Collection System Inspect Non Sampling
E-PMEWEWIC417
Permit Inspection Type: Collection system management and operation
Facility Status: ❑ Compliant E Not Compliant
Question Areas:
Miscellaneous Questions General Sewer&FOG Ordinances
Capital Improvement Plan Map Reporting Requirements
Inspections Spill Response Plan Spills
Lines Manholes Pump Stations
(See attachment summary)
Page 1 of 7

Docusign Envelope ID:C90047FA-7973-4C80-A466-67484CA08CFB
Permit: WOCS00293 Owner-Facility:Aqua North Carolina Inc
Inspection Date: 07/10/2024 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Inspection Summary:
Overall collection system was compliant with observations made during the inspection. ORC designation is required and
needed. Collection system program is non-compliant without a designated ORC.
Page 2 of 7

Docusign Envelope ID:C90047FA-7973-4C80-A4B6-67484CA08CFB
Permit: WOCS00293 Owner-Facility:Aqua North Carolina Inc
Inspection Date: 07/10/2024 Inspection Type :Collection System Inspect Non Sampling Reason for Visit: Routine
General Yes No NA NE
Is there a properly designated primary ORC and at least one back-up of proper grade? ❑ 0 ❑ ❑
Are logs being reviewed by the system management or owner on a regular basis? M ❑ ❑ ❑
#What is that frequency? Weekly
#Are there any issues being addressed currently or any in the planning stages? M ❑ ❑ ❑
Is there a specific pump failure plan available for all pump stations? M ❑ ❑ ❑
Does plan indicate if pump parts/new pumps are in spare parts/equipment inventory? ❑ ❑ ❑
Are new/significantly upgraded pump stations equipped with anti-corrosion materials? ❑ ❑ ❑
Does the permittee have a copy of their permit? 0 ❑ ❑ ❑
#Is permit expiring within the next 6 months? 0 ❑ ❑ ❑
If Yes,has the Permittee applied for renewal? ❑ 0 ❑ ❑
Comment: No ORC listed with DWR. Sending a DWR ORC Designation Form. Mr. Bishop indicated that
Ashley Kilinger will be designated ORC and will complete and submit form.Chemical degreaser
is being fed to help clean force mains. Permit expires January 31, 2025, reminded Mr. Bishop
of 6-month application for renewal sumittal.
Sewer and FOG Ordinances Yes No NA NE
Is Sewer Use Ordinance(SUO)or other Legal Authority available? 00 ❑ ❑
Does it appear that the Sewer Use Ordinance is enforced? No ❑ ❑
Is there a Grease Control Program that legally requires grease control devices? M ❑ ❑ ❑
What is the standard grease trap cleaning requirement in the FOG ordinance? Quarterly
Is Grease Control Program enforced via periodic inspections+records review? 0 ❑ ❑ ❑
Is action taken against violators? Cl 0 ❑ ❑
#Have satellite systems adopted an equivalent or more stringent ordinance? M ❑ ❑ ❑
Is grease/sewer education program documented with req'd customer distribution? so ❑ ❑
#Are other types of education tools used like websites, booths, special meetings. etc? ❑ M ❑ ❑
If Yes,what are they?(This can reduce mailing to annual.)
Comment: SUO is managed at Corporate level. No enforcement has taken place, clubhouse compliant.
Caaital Improvement Plan Yes No NA NE
Has a Capital(CIP)or System Improvement Plan been developed and adopted? ❑ ❑ 0 ❑
Is it designated for wastewater only or does it have a dedicated section? ❑ ❑ 0 ❑
Does CIP cover three to five year period of earmarked improvements? ❑ ❑ M ❑
Does CIP include description of project area? ❑ ❑ M ❑
Does CIP include description of existing facilities? ❑ ❑ 0 ❑
Does CIP include known deficiencies? ❑ ❑ M ❑
Does CIP include forecasted future needs? ❑ ❑ M ❑
Page 3 of 7

aoc.js gn Envelope ID:C90047FA-7973-4C80-A466-67484CA08CFB
Permit: WQCS00293 Owner-Facility:Aqua North Carolina Inc
Inspection Date: 07/10/2024 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Comment: System improvement is managed under regulations through the NC Utilities Commission.
Permittee manages improvements and repairs through annual budget planning.
Map Yes No NA NE
Is there a overall sewer system map? 0 ❑ ❑ ❑
Does the map include:
Pipe Type(GS/FM) 0 ❑ ❑ ❑
Pipe sizes 0 0110
Pipe materials(PVC,DIP,etc) 0 ❑ ❑ ❑
Pipe location 0000
Flow direction 0 ❑ ❑ ❑
Approximate pipe age M ❑ ❑ ❑
Pump station ID, location and capacity 0 ❑ ❑ ❑
# Force main air release valve location&type 0 Cl ❑ ❑
# Location of satellite connections M ❑ ❑ ❑
Is the map being updated for changes/additions within 1 year of activation? 0 ❑ ❑ ❑
Comment:
Reporting Requirements Yes No NA NE
#Have there been any sewer spills in the past 3 years? 0 ❑ ❑ ❑
If Yes,were they reported to the Division if meeting the reportable criteria? M ❑ ❑ ❑
If applicable, is there documentation of press releases and public notices issued? ❑ ❑ 0 ❑
Is an Annual Wastewater Performance Report being filed with the Division, if required? ❑ ❑ 0 ❑
Is the report being made available to all its sewer customers? ❑ ❑ 0 ❑
# How is it being made available?
Comment: System is less than 200,000 gpd average.
Inspections Yes No NA NE
Are adequate maintenance records maintained? 0 ❑ ❑ ❑
Are pump stations being inspected at the required frequency? 0 ❑ ❑ ❑
#Is at least one complete functionality test conducted weekly per pump station? 0 ❑ ❑ ❑
Is there a system or plan in place to observe the entire system annually? 0 ❑ ❑ Cl
Is the annual inspection documented? 0 ❑ ❑ ❑
#Does the system have any high-priority lines/locations? ❑ M ❑ ❑
Are inspections of HPL documented at least every 6 months? ❑ ❑ 0 ❑
Are new lines being added to the HPL list when found or created? ❑ ❑ ❑
Comment: No high priority lines listed in the pernit or known by the operator/permittee.
Spill Response Action Plan Yes No NA NE
Page 4 of 7

Docusign Envelope ID:C90047FA-79734C80-A466-67484CA08CFB
Permit: WOCS00293 Owner-Facility:Aqua North Carolina Inc
Inspection Date: 0711012024 Inspection Type:Collection System Inspect Non Sampl ng Reason for Visit: Routine
Is a Spill Response Action Plan available? M ❑ ❑ ❑
Is a Spill Response Action Plan available for all personnel? 0 ❑ ❑ ❑
Does the plan include:
24-hour contact numbers N ❑ ❑ ❑
Response time ■ ❑ ❑ ❑
Equipment list and spare parts inventory M ❑ ❑ ❑
Access to cleaning equipment 0 ❑ ❑ ❑
Access to construction crews,contractors,and/or engineers 0 ❑ ❑ ❑
Source of emergency funds 0 ❑ ❑ ❑
Site sanitation and cleanup materials 0 ❑ ❑ ❑
Post-overflow/spill assessment 0 ❑ ❑ ❑
Does the Permittee appear to respond within 2 hours of first knowledge of a spill? 0 ❑ ❑ ❑
Comment: 60 minute response time
illIRLS Yes No NA NE
Is system free of known points of bypass? so ❑ ❑
If No,describe type of bypass and location
Are all spills or sewer related issues/complaints documented? ■ ❑ ❑ ❑
#Are there repeated overflows/problems(2 or more in 12 months)at same location? E ❑ ❑ ❑
#If Yes,is there a corrective action plan? E ❑ ❑ ❑
Comment: Two spills were associated with one location with the same event.
Lines/Right-of-Ways/Aerial Lines Yes No NA NE
Please list the Lines/Right of Ways/Aerial Lines Inspected:
Gravity and force main lines associated with roadways and maintianed right-of-ways. Observed maintained
shoulders and medians throught neighborhood/service area.
Are right-of-ways/easements maintained for full width for access by staff/equipment? E ❑ ❑ ❑
If No,give details on temporary access:
Is maintenance documented? ❑ ❑ ❑
Are gravity sewer cleaning records available? E ❑ ❑ ❑
Has at least 10%of lines older than 5 yrs been cleaned annually? E ❑ ❑ ❑
Were all areas/lines inspected free of issues? N ❑ ❑ ❑
Comment: Majority of right-of-way maintenance conducted by landscaping maintenance or homeowners.
Manholes Yes No NA NE
Please list the Manholes Inspected:
Inspected manhole at Walker Falls Road upstream of Walker Wood Pump Station.
Are manholes accessible? ❑ ❑ ❑
#Are manhole covers/vents above grade? E ❑ ❑ ❑
Are manholes free of visible signs of overflow? N ❑ ❑ ❑
Page 5 of 7

Docusign Envelope ID: C90047FA-7973-4C80-A4B6-67484CAi.8C=B
Permit: WQCS00293 Owner-Facility:Aqua North Carolina Inc
Inspection Date: 07/10/2024 Inspection Type Collection System inspect Non Sampling Reason for Visit: Routine
Are manholes free of sinkholes and depressions? 0 ❑ ❑ ❑
Are manhole covers present? M ❑ ❑ ❑
#Are manholes properly seated? 0 ❑ ❑ ❑
#Are manholes in good condition? 0 ❑ ❑ ❑
#Are inverts in good condition? 0 ❑ ❑ Cl
Is flow unrestricted in manholes? 0 ❑ ❑ ❑
Are manholes free of excessive amounts of grease? M ❑ ❑ ❑
Are manholes free of excessive roots? 0 ❑ ❑ ❑
Are manholes free of excessive sand? M ❑ ❑ ❑
Are manhole vents screened? ❑ ❑ M ❑
Are vents free of submergence? 0 Cl ❑ ❑
Are manholes free of bypass structures or pipes? M ❑ ❑ ❑
Comment: Very small gravity service area -4,023 feet of gravity sewer in the system.
Pump Stations Yes No NA NE
Please list the Pump Stations Inspected:
Walker Woods, East Church, Clubhouse,South Enterance
#Number of duplex or larger pump stations in system
#Number of vacuum stations in system
#Number of simplex pump stations in system
#Number of simplex pump stations in system serving more than one building 0
How many pump/vacuum stations have:
# A two-way"auto polling"communication system(SCADA)installed? 8
# A simple one-way telemetry/communication system(auto-dialer)installed? 0
For pump stations inspected:
Are they secure with restricted access? 0111111
Were they free of by-pass structures/pipes? 0 ❑ ❑ ❑
Were wet wells free of excessive grease/debris? M ❑ ❑ ❑
# Do they all have telemetry installed? 0 ❑ ❑ ❑
Is the communication system functional? M ❑ ❑ ❑
Is a 24-hour notification sign posted? M ❑ ❑ ❑
Does the sign include:
Owner Name? ❑ ❑ ❑
Pump station identifier? ❑ ❑ ❑
# Address? M ❑ ❑ ❑
Instructions for notification? 0 ❑ ❑ ❑
24-hour emergency contact numbers? 0 ❑ ❑ ❑
Page 6 of 7

Docusign Envelope 10:C90047FA-7973-4C80-A4B6-67484CAOBCFB
Permit: WQCS00293 Owner-Facility:Aqua North Carolina Inc
Inspection Date: 07/10/2024 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Are audio and visual alarms present? 0 Cl ❑ ❑
Are audio and visual alarms operable? M ❑ ❑ ❑
#Is there a backup generator or bypass pump connected? ❑ M ❑ ❑
If tested during inspection,did it function properly? ❑ ❑ 0 ❑
Is the back-up system tested at least bi-annually under normal operating conditions? M ❑ ❑ ❑
#Does it have a dedicated connection for a portable generator? 0 ❑ ❑ ❑
#Is the owner relying on portable units in the event of a power outage? 0 ❑ ❑ ❑
#If Yes, is there a distribution plan? 0 ❑ ❑ ❑
If Yes,what resources(Units/StaffAtehicies/etc)are included in Plan?
3 mobile generators available.Generators would be rotated where needed to maintain system.With homes
being on simplex systems most power outages result in lower flows to the duplex lift stations.Contracted
services are also available if needed for generators or pump and haul operations.
#Does Permittee have the approved percentage of replacement simplex pumps? M ❑ ❑ ❑
Is recordkeeping of pump station inspection and maintenance program adequate? M ❑ ❑ ❑
Do pump station logs include at a minimum:
Inside and outside cleaning and debris removal? 0 ❑ ❑ ❑
Inspecting and exercising all valves? 0 ❑ ❑ ❑
Inspecting and lubricating pumps and other equipment? 0 Cl ❑ ❑
Inspecting alarms,telemetry and auxiliary equipment? 0 ❑ ❑ ❑
Comment:
Page 7 of 7

Docusign Envelope ID:C90047FA-7973-4C80-A4B6-67484CA08CFB
Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Farm
Facility Name: Permit#
Facility Type/Classification: Select Facility Grade: Select SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name:
Email Address:
Permittee Signature: Date:
ORC
Full Name: Work Phone:
Email Address:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
certify that!agree to 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 ISA NCAC 08G.0104 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"l certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. l understand and►tell abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in 1 SA NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"7 certify that I 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 I5A NCAC 08G.0204 and foiling to do so con result in Disciplinary Actions by the WPCSOCC"
Email this form to:[e-mail]
AND
Send to your DEQ Regional Office(send to your contact or find emails here:www.deq.nc.gov/about/contact/regional-offices
or fax using this drop down list: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 0212024

aocusign Envelope ID.C90047FA-7973-4C80-A4B6-67484CA08CFB
Facility Name: Permit#:
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"l certify that l agree to my designation as the Operator in Responsible Charge for the facility noted. l understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in ISA NCAC 08G 0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"I certify that 1 agree to my designation as the Operator in Responstbh-Charge for the facrlity noted i understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A NCAC 08G.0204 and failing to do so can result in Duciphnory Actions by the WPCSOCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: __.. Effective Date:
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-
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"t certify that 1 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 asset forth in 15A NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Revised 02/2024