WQ0035784_ORC Designation Form_20240903

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Timberline Real Estate Ventures c/o Andrew Stark
Email Address: [e-mail]
Permittee Signature: Date:
Facility Name: The Cottages of Boone Permit # WQ0035784 NCO089991
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: WW-II
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: David Aaron Rogers
Certificate Type: WW
Certificate Grade: IV
Email Address: [e-mail]
Work Phone: 0828
Certificate #:
734-1314
102458
Dlyflally signed by: David Rogers 9/3/2024
Signag David Rogers°N=David Rogers nk,1- tlrU= ORenvirolinkinc.
ture: C=U50=Envirolink,Inc.0U=0RC Effective Date:
"I certify that 1 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 Water Pollution Control System Operators Certification Commission."
Print Full Name: Todd Franklin Robinson
Certificate Type: WW
BACKUP ORC
Certificate Grade: IV
Email Address: [e-mail]
Signature:
rally mI e,: road Ronm.o�
Todd Robinson a =.rRnem.namall-aoemao�awrolmmneeom
._ 2 O 09,04 EnNmlln552 Inc.­ao
Work Phone: [phone]
Certificate #: 989809
Effective Date: 9/3/2024
"1 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 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mill Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Fax: [phone] Phone:
Phone: [phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 1112020

Page 2
Facility Name: The Cottages of Boone
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Certificate Grade: Select
Permit #: NCO089991
Work Phone:
Certificate #:
Signature: Effective 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 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."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"I certify that/ 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:
BACKUP ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"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."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"I certify that/ 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 1112020