WQCS00011_ORC Designation Form_20240822

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: Tar River Reginal Collection System
Permit # WQCS00011
Facility Type/Classification: CS 0 Facility Grade: IV F-1 SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: City of Rocky Mount / Brenton Bent
Email Address: [e-mail]
Permittee Signature: U
ORC
Full Name: Jason Britt Glover
Email Address: jason.glover@rockymountnc. ov
Certificate Type: CS Q
Date: 51� 2_/-Zo.ZT
Work Phone: [phone]
Certificate Grade: IV 0 Certificate #: 1001663
Signature: AEffective Date: ?' l Z - Z y
"I certify that 1 agree to my esi anon as the Operat Responsible Charge for the facility noted. 1 understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Blake Nicholas Winstead
Certificate Type: CS 0 Certificate Grade: III
0
Work Phone: [phone]
Certificate #: 998007
Signature: /.t��G��"`� �� Effective Date: q-1 — y
"I certify that 1 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 asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Taylor Ray Joyner
Work Phone: [phone]
Certificate Type: CS 0 Certificate Grade: Certificate #: 1004178
Signature: Effective Date: 9 — 12 _ 262 y
"1 certify that I agree to my deli nation a Operator in R ponsible Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibilities of the ORC asset forth in 15A 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 emails here: www.deq.nc.gov/about/contact/regional-offices
or fax using this drop down list: Raleigh-3800 Barrett Dr.,Raleigh, NC 27609 1 FAX: [phone] PH: 919-791-4200
Use the 2nd page only if you need to list additional Backups.
Revised 0212024

Facility Name: Tar River Reginal Collection System
Permit M WQCS00011
Backup ORC
Full Name: James Christopher Parker Work Phone: [phone]
Certificate Type: CS 0 Certificate Grade: IV 0 Certificate #: 1007862
Signature: Effective Date:
- Cl/ � �,4
"1 certify that 1 agree to my d gnation as the Operator in Responsible Charge for the facility noted. 1 understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"1 certify that 1 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"
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"I certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted.
1 understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the WPCSOCC"
Backup OR
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"1 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 asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Revised 0212024