WQCS00297_ORC Designation Form_20240806

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: TOWN OF LILLINGTON Permit # WQCS00297
Facility Type/Classification: CS Facility Grade: II SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Joseph Jeffries
Email Address: Jeffries lillin tonnc.or %
Permittee Signature: Date: L
ORC
Full Name: Daniel Gordon Turlington
Work Phone: [phone]
Email Address: dturlin ton lillin tonnc.or
Certificate Type: CS Certificate rade: II
Certificate ##: 1013467
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Signature:
Effective Date: R - �- �O� Lj
"1 certify that I agree signation as the Operator in Responsible Charge for the facility noted.
! understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as setforth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Skyler Mason Russell
Work Phone: [phone]
Certificate Type: CS Certificate Grade: ll
Certificate #: 1005824
Signature:
Effective Date: p G - a e/
"i 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 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:
"1 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 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: Fayetteville-225 Green St., Suite 714, Fayetteville, NC 28301-50431 FAX: [phone] PH: 910-433-
use the 2nd page only if you need to list additional Backups.
Revised 0212024