NC0025453_ORC Designation Form_20240828

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Farm
NCAC 15A 8G .0201
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Facility Name: Sam's Branch Water Reclamation Facility Permit #
NCO025453
Facility Type/Classification: WW E] Facility Grade: IV 0 SUBMITA SEPARATE FORM FOR EACH CLASSfF1CATION
Permittee Owner/Officer Name: .lames Blalock
Email Address: [e-mail]
Permittee Signature: 1- - Date:
ORC
Full Name: David White
Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW __ ] Certificate Grade: IV 0 Certificate #: 1011005
Signature: Effective Date:
"I certify that l 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 failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Brian Gay Work Phone:
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #:
Signature: `"",Ja-h Effective Date:
[phone]
9187
"i certify that I agree to my designation as the Operator iT R-14ponsible 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 NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: James Warren
Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 7149
Signature: d Lzk, Effective Date: S 1 %r L 1.1
"I certify that l agree to my d i ation as the Operator in Responsible Charge far the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibi res of the ORC as set 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: Raleigh-3800 Barrett Dr.,Raleigh, NC 276091 FAX: [phone] PH: 919-7914200 0
Use the 2nd page only if you need to list additional Backups.
Revised 0212024