WQCS00366_ORC Designation Form_20240820

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
Facility Name:
White Oak Estates
Facility Type/Classification: CSVF
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Grade: -
Permit # WQCS00366
LO
lIBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Carolina Water Service, Inc. of NC /TDny Ionsuo
Email Address,-0
[e-mail]
.bDigitally signed by Tony Konsul
OU="Vice President, Operations", O=Carolina Water Service of NC,
ony Konsul, E=[e-mail]
n: I am approving this document
Perrnittee
LT
T
on: Charlotte, NC
V: 2024.08.20 12:09.10-04 00
Foxit PD .1 date
'
Full Name:
Email Address:
Certificate Type
ORC
6?12 0 / -20 z
John Maypole work Phone: [phone]
[e-mail]
CS Q Grade: �� 0Certificate Certificate #t:
1011404
Signature: V effective Date: 08/20/2024
ir 9
"r certify that I agree to my de/siotrnos tine Operator in Re ponsible Charge for the facility noted. 1 understand and wiJl abide by the rules and regulations pertaining
to the responsibiJiriesvf the 4forth in 15A NCAC 08G. 0204 and ailing to do so can result in Disci'pli'nory Actl'ons by the WPCSOCC'
Full Name:
Certificate Type
Backup ORC
Anthony Futrell
CS Q Certificate Grade: IV Q
Work Phone: (312)
Certificate #:
965-3728
1009027
Si nature: � Effective Date0 08/2012024
"1 certify that 1 agree to my designatiorl0os the Operotor in Responsible Charge for the focifity noted. !understand and will ❑bide by the rules and regulations pertaining
to the responsr6il;ties of the SRC as set forth in I SA NCAC 08G. 0204 ❑nd fai-ling to do so con result in Disciplinory Actions by the WPCSOCC A0
Full Name:
Certificate Type
Select
Backup ORC
Cifi
ertcate Grade: Select
Work Phone:
Certificate #:
Signature.-- Effective Date.:
'I certrfy that /agree to my designotion as the Operator in Responsible Charge for the facility noted. 1 understand ond will ❑bide by the rules and regulations
pertoining to the responsibrlitr`es of the SRC as setforrh in 15A NCAC 08G .0204 and jailing to do so con 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 emails here: www.deq.nc.gov
or fax using this drop down list: Choose DWR Regional Office that has coverage of this facility.
/abOLIt/contact/reg'i'onal-offoices
Use the 2nd page only if you need to list additional Backups,
Revised 0212024