WQCS00201_ORC Designation Form_20240807

John L. Chandler
Mayor
Nicholas A. Honeycutt
Town o Mars flill tW.Zi or
Robert W. Zink
Treasurer
Stuart L. Jolley
Clerk
Lang H. Davis
Secretary
WPCSOCC
ATTN: ORC Designation
1618 Mail Service Center
Raleigh, NC 27699-1618
RE: TOWN OF MARS HILL —
August 8, 2024
SENT VIA ELECTRONIC MAIL TO:
[e-mail]
PERMIT #: WQCS00201 AND PERMIT #: NCO057151
WWTP ORC & COLLECTION SYSTEM ORC DESIGNATION CHANGE
To Whom It May Concern:
Please be advised that the Town of Mars Hill requests the WWTP ORC and collection system
ORC for the Town of Mars Hill System to be changed. I have enclosed two separate designation forms
requesting your approval of this change.
I appreciate your consideration of this request. Please contact me should you have any questions
or require additional information.
Enclosures as stated
cc: Asheville Regional Office (by US Mail)
Sincerely,
1 w'
NATHAN R. BENNETT,
Town Manager
Mars Hill Town Hall
280 North Main Street • P.O. Box 368
Mars Hill, North Carolina 28754
Phone: [phone] • Fax: [phone]
www.townofmarshill.org

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: TOWN OF MARS HILL - NATHAN BENNETT
Mailing Address: PO BOX 368
City: MARS HILL
Phone: [phone]
State: NC Zip: 28754
Email Address: [e-mail]
Signature:
Facility Name: TOWN OF MARS HILL
County: MADISON
Date: j' 6 70 Zy
Permit # WQCS00201
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: CS
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: TOMMY DEAN WORLEY Work Phone: [phone]
Certificate Type: CS
Certificate Grade: II
Email Address: [e-mail]
Certificate #: 1010333
Signature: Date: g'd r�- o otQL
"1 certify that / agree to my iesignotion as t e 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: JAMES GARRETT FOX Work Phone: [phone]
Certificate Type: CS
Certificate Grade: I
Email Address: [e-mail]
Certificate #: 1015074
Signature: Date: (37- O7a- �,G92S9
"l certify that / agre to my design tion as a Back-up 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 NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued)
Page 2
Facility Name: TOWN OF MARS HILL Permit #: WQCS00201
BACKUP ORC
Print Full Name: JASON ROY RIDDLE Work Phone: [phone]
Certificate Type: CS Certificate Grade: I Certificate #: 1002918
Email Address: [e-mail]
Signature: Date: 6-7- a 0a1
"I certify that/ agre o my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regul tions pertaining to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in
r)krinlinnry Artinnc hu tho Writor Pn/lutinn r'nntrnl C'vcf m nncrntnrc rortifirntinn (nmmiccinn1.
"
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"I certify that/ agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"1 certify that/ agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"I certify that/ agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
Revised 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: TOWN OF MARS HILL - NATHAN BENNETT
Mailing Address: PO BOX 368
City: MARS HILL State: NC
Email Address: [e-mail]
Phone: [phone]
Zip: 28754
Signature: ? C04_�Ve Date:
Facility Name: TOWN OF MARS HILL
County: MADISON
Permit # NCO057151
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: TOMMY DEAN WORLEY Work Phone: [phone]
Certificate Type: WW Certificate Grade: II
Email Address: [e-mail]
Certificate #: 1015427
Signature: —�i�f&7Date:
"1 certify that 1 agree to my c4signation as thl 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: JAMES GARRETT FOX Work Phone. [phone]
Certificate Type: WW Certificate Grade: I
Email Address: GFOX@TO\NNOFMARSHILL.ORG
Certificate #: 1015381
Signature: �r-(� Date: �` C7— '�
"1 certify that I agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: TOWN OF MARS HILL Permit #: NCO057151
BACKUP ORC
Print Full Name: JASON ROY RIDDLE Work Phone: [phone]
Certificate Type: WW Certificate Grade: II Certificate #: 1005656
Email Address: [e-mail]
Signature: Date: -7
"'/ certify that / ogr to my designation as a Back-up 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in
nicrinlinnn/ Lrfinnc by f o Wrytor Pnlhitinn ('nntrnl Ciecfiom ()norntnrc rorfifi�nl inn rnm ccinn -
wy .. v..H �..�„ vv„�, v, Sy"',,, —j", —,—, a a.. �,, "j ,a, a., �,v„ t�v,,,,,,,a.,
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"l certify that l agree to my designation as a Back-up 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"l certify that l agree to my designation as a Back-up 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"'/ certify that / agree to my designation as a Back-up 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 412016