NC0004723_ORC Designation Form_20240827

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Novigote Form
Facility Name: CHARLOTTE TERMINAL 3
Permit # NCO004723
Facility Type/Classification: PC Facility Grade: I SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Kinder Morgan Southeast Terminals ! Wayne Harvey
Email Address: [e-mail]
Permittee Signature: /
ORC
Date: 8/27/24
Full Name. Joseph Byers Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: PC Certificate Grade: I Certificate #: 1010231
Signature:
i` Effective Date: Y_
"I certify that I 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 os set forth in ISA NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Matthew Joseph Brundage Work Phone: [phone]
Certificate Type: PC Certificate Grade: I Certificate #: 1002738
Signature: `�"`F'`"" ��G Effective Date: August 26, 2024
"I certify that I 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 15A NCAC08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Gary W Simcox Work Phone: [phone]
Certificate Type: PC Certificate Grade: I Certificate #: 28893
Signature: Effective Date: August 26, 2024
"I certify that I 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 I5A NCAC 08G.0204 and failing to do so can 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: Mooresville-610 E. Center Ave., Suite 301, Mooresville, NC 28115 l FAX: [phone] PH: 704-663-1,
Use the 2nd page only if you need to list additional Backups.
Revised 0212024

Facility Name: CHARLOTTE TERMINAL 3 Permit#: NC0004723
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"I certify that I agree to my designation as the Operator In Responsible Chorgefor the facility noted.
I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORCos set forth in 15A NCAC08G.0204 ondfailing 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:
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 ORCas set forth In 15A NCAC08G.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 I agree to my designation as the Operatorin 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 NCAC08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup OR
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"I certify that I agree to my designation as the Operotorin Responsible Charge for the facility noted.
I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORCos set forth In 15A NCAC08G.0204 and failing to do so can result n
Disciplinary Actions by the WPCSOCC"
Revised 0212024