WQ0022224_ORC Designation Form_20240828 (3)

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Sam's Branch Water Reclamation Facility Permit#
WQ0022224
Facility Type/Classification: WW 0 Facility Grade: IV E SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permiittee Owner/Officer Name: James Blalock
Email Address: [e-mail]
Permittee Signature: Date:
ORC
Full Name: David White Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW E] Certificate Grade: IV 0 Certificate #: 1011005
Signature:z.�r Effective 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 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Brian Gay
Certificate Type: WW 0 Certificate Grade: IV 0
Work Phone: [phone]
Certificate #: 9187
Signature: Effective Date:�r�`"
certify that I agree to my designation as the Operat6aResponsible 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: James Warren
Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 7149
Signature: Effective Date: S 1 2 � 2 V
"I certify that 1 agree to y signation as the Operator in Responsible Chorge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the respon ilities of the ORC as set 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 0
Use the 2nd page only if you need to list additional Backups.
Revised 0212024