NC0044253_ORC Designation Form_20240819

© WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FOR
M (WPC50CC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: CAMP DOGWOOD 1 NC LIONS, INC.
Email Address: [e-mail]
Permittee Signature: Me*
Facility Name: CAMP DOGWOOD WWTP
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION:
ORC - OPERATOR 1N R
Print Full Name: CRYSTAL RICHARDSON HUTCHENS
Certificate Type: WW
Certificate Grade: IV
WW-II
Date: . 2—
Permit # NCO044253
E`
Work Phone: [phone]_
Certificate #: 1015513
Email Address: CHUTCHENS@ENVIROLINKIN C.COM
C?�Y y7� W: Crystd NirtNmn
C stal Hutchensn. ""'`''�''"°° 8/19/2024 Signature: ­=, �C-US0-E , * Effective Date:
'7 certify that 1 agree to my designation as the°Z3pe'raF'dr in'#esponsibie Charge for the facility noted. 1 understand and will abide by the
rules and regulations pertoining 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: TODD FRANKLIN ROBINSON
Certificate Type: WW
Certificate Grade. 1V
Work Phone: [phone]
Certificate #: 989809
Email Address: [e-mail]
pp� 7�
Todd Robinson°�.�N,T�d-
5ignature: elW,PtnwnQrn mtinhi�C=USUIEnnrdiak. Effective Date: 8/19/2024
'7 certify that I agree to my designation as a 8ac&"UP'VAJF?6ff "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 086.0204 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, Raleigh, NC 27699-1618
ORIGINAL to: Email:[e-mail] Fax:[phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 1112020

Page 2
Facility Name: CAMP DOGWOOD WWTP
Permit #: NCO044253
BACKUP ORC
Print Full Name: KERRY MILLER Work Phone: [phone]
Certificate Type: WW Certificate Grade: , IV Certificate #: 1014970
EmailAddress: [e-mail]
Ilgblly Signed W. Kant' MAW
cw = Kent' Mares amad = 8/19/2024
Signature: �"", ,'�a,�,am,'aUnklnceomC=Uso- Effective Date:
fE .l.-Iink. Inc
"i certify that I agree to my designation as a BaokaLpOperQtanacrbAesponsible 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 NCAC08G.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
Email Address:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that 1 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
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"I 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."
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
"1 certify that I agree to my designation 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."
Revised 1112020