WQCS00236_ORC Designation Form_20240807

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Town of Littleton
Permit # WQCS00236
Facility Type/Classification: CS 0 Facility Grade: I E SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Heidi Hogan, Mayor
Email Address: [e-mail]
Permittee Signature: Date: O t- 05/:z
ORC
Full Name: David Scott
Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: CS FZ1 Certificate Grade: IV FZ1
Certificate #: 999152
Signature: I W r�
Effective Date: OS-1 —67 - 262 �
"1 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:
"/ 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"
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. 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:[ Raleigh 3800 Barrett Dr Raleigh NC 276091 FAX: [phone] PH: 919-791-4200
Use the 2nd page only if you need to list additional Backups.
Revised 0212024

To whom it may concern,
Please see attached ORC designation form. We have submitted the online ORC resignation form to
remove Luke Compton as our ORC for the collection system. Please remove him from the permit
and leave all other Backup ORC's as they are.
Heidi Hogan, Mayor.
�du&" 4'17c"t t W 7 Ot- d a-/051AV