WQ0015052_ORC Designation Form_20211129

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: Willjam Freed
Mailing Address:. -P.O. Box 92
City: Harbinger _ State: NC Zip: 27941 _ Phone #: [phone]
Email address: [e-mail]
Signature: - - - -_ Date: — - - tI 2q i 2vZ
...........a................................... ...... .......a................ ............................. ...................................
Facility Name: Villages & Ocean Hill- WWTP
Permit #: W00015052
County: - Currituck —
.......... .............................................. ............. ............. ............................. . ...........................
...!
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
../................................................a................................. 1.a....s.....a...aU.a..a............................. I
Operator in Responsible Charge (ORC)
Print Full Name: GregShelton -_ Email:_ [e-mail] _
Certificate Type / Grade / Number: Grade 2 - 991875 — Work Phone #: [phone]
Signature: 2E_XU Date:
"I 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 as set forth in 15A NCAC 09G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
...• ......... ...................... .......... ................. ....... ............. V......... .......... o........0.0.....o.....................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Noah Deckard Ell; [e-mail]
Certificate Type / Grade / Number: Grade 2-1009715 Work Phone #: [phone]
Signature: 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 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."
...............................................................................................................................................•
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
on n 1 to: Email: certadmin al"kncdearaov
Mail or fax a gM to the Asheville
appropriate Regional Office: 2090 US Hwy 70
Swannanoa 28779
Fax: [phone]
Phone: 828.296A500
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: 910A33.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: 910.7%.7215
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]"
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:919.791A200
Revised 05 2015