WQ0015052_ORC Designation Form_20220205

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: William Freed
Mailing Address:
City: Harbinger
P.O. Box 92
State: NC Zip: 27941 _ — Phone #: [phone]
Email address: bfreed etuGs.com
Signature:Date:
...................... ......................................................:..............................................................
Facility Name: Villages CED Ocean Hills T Permit #: WQ0015052
County: _ CHrritHck
...............................................r............................................................................-6.....................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
................................................................................................................................................
Operator in Responsible Charge (ORC)
Print Full Name: —John Pruitt Email:— jpruitt envirolinkinc.com
Certificate Type / Grady / Number: WW4 >26021 Work Phone #: [phone]
r`
W
Signature: Date: 2/15/2022 _
"I certify that 1 agrec:in my designation as the Operator m 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."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: James Twiddy Email:_ jwtwiddy ci_envirolinkinc.com
Certificate Type i 'rade / N t WW1-994926 Work Phone #: [phone]
Signature: Date: Z ZA = 2Z
'4 -
I certify ist I agree to my designation as ack-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 BU ORC as set forth in I SA NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................... 0........
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
orSinal to: ;mall: certadmin(&nrdenr&n_X
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional ice. 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Phone:919.79 t.4200
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015