WQ0015052_ORC Designation Form_20200514

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: ENVIRO TECH OF NORTH CAROLINA INC, WiLLIAM G FREED
Mailing Address: PO BOX 59
City: HARBINGER
Email Address: [e-mail]
Phone: [phone]
State: NC zip: 27941
Signature: Date:
Facility Name: VILLAGE AT OCEAN HILL WWTP Permit # WQ0015052
County: CURRITUCK
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: JAMES BLIVEN Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: JBLIVEN@7a ENVIROLINKINC.COM
Signature:
Certificate #: 991879
Effective Date:
`7 certify that l agree to 4 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 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: DAVID ROBERTSON Work Phone: [phone]
Certificate Type: WW
Certificate Grade: III
Email Address: DROBERTSON[7a ENVIROLINKINC.COM
Certificate #: 987714
Signature: Effective Date: /YZ0
"1 certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. )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 con 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]
ORIGINALto: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett ❑r.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: VILLAGE AT OCEAN HILL WUVTP Permit #: WQ0015052
BACKUP ORC
Print Full Name: RANDALL MARRS work Phone:[phone]
Certificate Type: WW Certificate Grade: IV
Email Address: RMARIAENVIROLINKINC.COM
Certificate #: 1006386
Signature: vtrr Effective Date:
certify that 1 ogr e to m designation as a Back-up Operator in Responsible Charge for the facility noted. I understand aInd 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: ADAM ISENHOWARD Work Phone: [phone]
Certificate Type: WW
Email Address:
Signature:
Certificate Grade: I
Certificate #: 1006320
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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"I certify that I agree to my designation as a Bock -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 Certificate Grade: Select Certificate #:
Email Address:
Signature:
Effective Date:
"1 certify that i agree to my designation as a Back-up Operator in Responsible Charge for the focility 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 foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A SG .0201
Press TAB to enter information
Permittee Owner/Officer Name: ENVIR❑ TECH OF NORTH CAROLINA INC, WILLIAM G FREED
Mailing Address: PO BOX 59
City: HARBINGER
Email Address: BFREED tt7ETUCS.COM
Signature:
Facility Name: VILLAGE AT OCEAN HILL WVVFP
County: CURRITUCK
State: NC
Phone: [phone]
Zip: 27941
Date:
Permit # WQ0015052
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: CS
Facility Grade: Select
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: JAMES BLIVEN Work Phone: [phone]
Certificate Type: CS
Email Address: JBLIVE
Signature:
Certificate Grade: III
ROLINKINC.COM
Certificate ##: 988786
Effective date:-35_I1y-
"1 certify that I agree to my designation as the 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."
BACKUP ORC
Print Full Name: DAVI❑ ROBERTSON Work Phone..[phone]
Certificate Type: CS Certificate Grade: II Certificate #: 991844
Email Address: DROBERTSON@a ENViROLINKiNC.COM
Signature: Effective Date: �F`k,&_ c)
"9 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 asset 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax. [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 23301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal ❑r.
Wilmington, NC 28405-2.845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone:[phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: VILLAGE AT OCEAN HILL VVVVTP Permit #: WQ0015052
BACKUP ORC
Print Full Name: RANDALL MARRS Work Phone:[phone]
Certificate Type: CS
Certificate Grade: II
Email Address: RN6A$yRW_ENVIROLINKINC.00M
Certificate #: 994327
P r
Signature: i 4 Effective Date: 5 �Ind
`I certify that I agree to mVdesignation as a Back-up Operator in responsible Charge for the facility noted. l un erstandwill 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 Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"1 certify that l 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."
BACKUPORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature:
Effective Date -
"I certify that I agree to my designation as a Back-up 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 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. 1 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 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: ENVIRO TECH OF NORTH CAROLINA INC; WILLIAM G FREED
Mailing Address: PO BOX 69
City: HARBINGER
Email Address: [e-mail]
Signature:
Facility Name: VILLAGE AT OCEAN HILL WIlVfP
County: CURRITUCK
Phone: [phone]
State: NC Zip: 27941
Date:
Permit # WQ0015052
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: SI
Facility Grade: Select
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: JAMES BLIVEN Work Phone. [phone]
Certificate Type: SI
Certificate Gracie: Select Certificate #: 28243
Email Address: JBLIVEN [e-mail]
Signature:
Effective Date:
"7 certify that I agree to rl iy 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 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: DAVI❑ ROBERTSON Work Phone:[phone]
Certificate Type: Sl
Certificate Grade: Select Certificate #: 988715
Email Address: ❑[e-mail]
Signature: Effective Date::�`�i�f�2e�
"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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville Fayetteville Mooresville Raleigh
a COPY to: 2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone.[phone] Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq. Mall
127 Cardinal Dr.
45 W. Hanes Mall Rd.
Washington, NC 27889
Wilmington, NC 28405-2845
Winston-Salem, NC 27105
Fax; 252-946-9215
Fax; 910-350-2004
Fax: [phone]
Phone:[phone]
Phone:[phone]
Phone:[phone] Revised4/2016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: VILLAGE AT OCEAN HILL WVVFP Permit #: WQ0015052
BACKUP ORC
Print Full Name: RANDALL MARRS Work Phone: [phone]
Certificate Type: Sl
Email Address: RMI S EN'
Signature: f
Certificate Grade: Select Certificate #: 993133
LINKINC.COM
Effective Date: A -7'_L_0
"I certify that 1 agree to rly designation as a Back-up Operator in Responsible Charge for the facility noted. 1 understand aold will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .R204 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:
certify that l agree to my designation as a Back-up Operator in Responsible Charge far 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 NCAC 08G .0204 and falling 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 Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"1 certify that I agree to my designation as a Back-up 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 os 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 CRC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature:
Effective Date:
"l certify that 1 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 412016