WQ0022870_ORC Designation Form_20240816

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCQ
NCAC 15A 86.0201
Penmittee Owner/Officer Name:
Mailing Address:
City:
Email Address:
Signature:
Press TAN to enter fn formation
Aqua North Carolina- LorrairleStegner
202 Madtenan Court Phone:
Cary State: NC Zip: 27511
Facility Name: Chapel Ridge Permit # M0022870
County: Chatham
YOU MUST SUBMIT A S PAR U FORM FOR Mo TYPE AND CLASSIFICATION OF SYSTEM:
Fade Type:
81
Facil tV Grade:
11
I OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: 811111n Peters Work Phone: E19.602-4.+�9
Certificate Type: 81 Certificate Grade: Select Certificate N: 987582
EmallAddress: WPeters�4rc«tica�,�.r.,_«.
Sgnature: � � � Effective Date: klibg
certify that i agree to my designation as the Operator In Responses 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 1S4 NC4C Obi 4204 and failing to do so can result in
Disciplinary Actions by the Water Pollution► Control System Operators Certification commission. d
BACKUP ORC
Print Full Name: AVY Stone Work Phone: [phone]
Certificate Type: SI Certificate Grade: Select Certificate #:1015W
Email Address:
Signature: Effective Date: 8t 1 1 zy
"1 certify that i agree to my d4j4ration as ­aBack-up Operator in Responsible Charge far the facility rated. 1 understand and ON abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and foiling 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]
QgIG1NAl to: Raleigh, NC 27699-1619
Mail or Fax Asheville Fayetteville
a COPY to: 2090 US Hwy 70 22S Green St., Suite 724
Swannaraa, NC 28779 Fayetteville, NC 28301-5043
Fax:[phone] Fax:[phone]
Phone:[phone] Phone- 910-433-3300
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2945
Fax: 910-3S0.2004
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 2811S
Fax: [phone]
Phone: [phone]
Winston-Salem
4S W. Hanes Mail Rd.
Winston-Salem, NC 27105
Far. 336-776-9797
Phan*: 336-776-9800
Raleigh
3900 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone:[phone]