NC0025321_ORC Designation Form_20240815

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A SG .0201
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Facility Name: Town of Waynesville
Permit # NCO025321
Facility Type/Classification: WW F71 Facility Grade: IV 0 SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Gary Caldwell
Email Address: [e-mail]
Permittee Signature:
Date:
ORC
Full Name: Charles Robert Dills Jr
Work Phone: 82$ 476-2850
Email Address: [e-mail]
Certificate Type: WW 0 Certificate Grade: IV
Certificate #: 1014625
` �
Effective Date: �`/
Signature:
"1 certify that 1 agree to my designation as the Operator in Responsible Charge far 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 NCAC 08G , 0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Mark Allen Jones
Work Phone: [phone]
Certificate Type: WW __ El Certificate Grade: IV El
Certificate #: 26812
Signature: NIL
Effective Date: F - i--'
"f certify that 1 agree to my designation as the Operata n Responsible Charge far the focility noted.
l understand and will ❑bide by the rules and regulations pertaining
to the responsibilities of the ORC os set forth in 15A NCAC 08C .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full name: Eric Brandon Messer
Work Phone: [phone]
Certificate Type: WW [l Certificate Grade: IV 0
Certificate #: 1002175
Signature: �n_ _ Effective Date: 8'- /S-;t
"f Certify that 1 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 asset forth in 15A 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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised C212024

Facility Name: Town of Waynesville Permit #:
NCO025321
Backup ORC.
Full Name: Hiram Grant Tuft Work Phone: [phone]
Certificate Type: WW _ Certificate Grade: IV Certificate #: 1006407
Signature:
Effective Date: /5-2
"I certify that I agree to my designation as the Operator in Respons le 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 falling 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 Operator In Responsible Charge for thefacllity 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 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 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 falling to do so can result in Disciplinary Actions by the WPCSOCC"
Full Name:
Certificate Type: Select
Signature:
Backup ORC
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
"I certify that 1 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 15A NCAC 08G.0204 and falling to do so can result In Disciplinary Actions by the WPCSOCC"
Revised 0212024