NC0038300_ORC Designation Form_20240501

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name:
SS MOBILE HOME PARK
Permit # NCO038300
Facility Type/Classification:
WW
Facility Grade:
11 SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name:
SS
Construction and
Rental, Inc.
Email Address:
tri
Permittee Signature
ORC
Full Name: James R Edwards
Email Address: [e-mail]
Certificate Type: WW
Certificate Grade: 11
Work Phone:
Certificate #:
25149
i
Signature: Effective Date: .57
"I certify that I agree o y 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 ' he 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: Frederick R. Thomen Work Phone:
Certificate Type: WW
Signature:
Q
Certificate Grade: 11
Certificate #
26007
Effective Date:
'I 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"
Full Name:
Certificate Type: Select
Signature:
Backup ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
`I 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 con result in Disciplinary Actions by the WPC5OCC'
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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 0212024