NC0074268_ORC Designation Form_20240823

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: CROWDERS CREEK WWTP
Facility Type: WW Facility Grade: IV
Permit # NCO074268
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: CITY OF GASTONIA / STEPHANIE SCHERINGER
Email Address: [e-mail]
Permittee Signature: Date: ?410•a4
ORC
Operator in Responsible Charge
Full Name: Thomas Carlos Lopez Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW Certificate Grade: IV Certificate #: 1012910
Signature: Effective Date: u 124,2�
"1 certify th 1 agree to my designation as the Operator in Responsible Charge for the facility noted. 1 understand and will
abide by t e 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
Full Name: Justin Thomas Starnes Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 1011369
Signature: �— Effective Date:
1 tify 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."
Backup ORC
Full Name: Michael Charles Graham Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 28534
Signature: C - Effective Date: X124 /760fi
"1 certify that 1 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."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC27699-1618 1 FAX:[phone] [e-mail]
Mail or fax a COPY to: Mooresville-610 E. Center Ave., Suite 301, Mooresville, NC 28115 1 FAX: [phone] PH: 704-663-1699
Revised 312019

Facility Name: CROWDERS CREEK WWTP
Full Name: Kevin Morgan Graves
Certificate Type: WW Certificate Grade: IV
Permit #:
Work Phone:
Certificate #:
Page 2
NCO074268
[phone]
999374
Effective Date: 093/ /ZO2 1
Signature: I
"1 certify tha agree to Wdesignation 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."
Full Name: Edward Allen Walter
Certificate Type: WW Certificate Grade: III
Work Phone: [phone]
Certificate #: 1015502
Signature: & AN Effective Date: ? �-6 - ZI'f
"I certify that 1 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."
Full Name: Elisha Baker Jr.
Certificate Type: WW Certificate Grade: IV
Work Phone:
Certificate #:
[phone]
991684
Signature: 9CV Effective Date: �"�t"Icertify that Iagree to my des nation as a Back-up Operator in Responsible Charge for the fcilitd 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."
Full Name: Brent Richard Lucas Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 1011679
Signature: �% `m=� / Effective Date: g-eZGZ
"1 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."

Page 2
Facility Name: CROWDERS CREEK WWTP
Full Name: Stefania R. Marroquin
Certificate Type: WW Certificate Grade: IV
Signature: Effective Date: Y%Z6 IZ02q
'Icertify tha 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."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate M
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."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate M
Signature: Effective Date:
1 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."
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate M
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 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."