WQ0012696_ORC Designation Form_20240809

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
Facility Name
NCAC 15A 8G .0201
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PAMLICO RIVER FERRY TERMINAL WWTF
Facility Type/Classification: SI
Permittee Owner/Officer Name:
Facility Grade: NIA
Catherine Peele
Email Address: cdpeele a&cdot.
Permittee Signature:
ORC
Permit # WQ0012696
SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
Date: 08/09/2024
Full Name: iI i M Work Phone: — —%�7
Email Address: 1 f
Certificate Type: Select SI Certificate Grade: Select JVIA Certificate #: 1 Oo$ppLP
Signature:—J.I'ue4 64r.� IlYt. Effective Date:
Jx
"I certify that I agree to my designation as the Operator in Responsible Charge far the facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in I5A NCAC 08G .0204 and failing to do so can result in DisciplinaryActions by the WKSOCC"
Backup ORC
Full Name: /Vacs h kG,y4 Work Phone:
Certificate Type: Select 4= Certificate Grade: Select Al/A Certificate #: I o i D ilp2Lp
Signature: Effective Date: q
"1 certify that 1 agree to my designation 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 set forth in ]SA NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSCCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Se- lect Certificate Grade: Select Certificate #:
Signature: Effective Date:
f certify that f 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 ISA 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 emai)s here: www.deq,nc.gov/about/contact/regional-offices
or fax using this drop down list: Washington-843 Washington Sq. Mall, Washington, NC 27889 1 FAX: [phone] PH: 252-346-648,
Use the 2nd page only if you need to list additianal Backups.
Revised 02/2024