WQCS00364_ORC Designation Form_20240904

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Press TAB to enter information
Rockingham County c/o Ronnie Tate
Email Address: [e-mail]
PermitteeSignature: hi'i2(c1 Date:
Facility Name: Rockingham County Collections System Permit #
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: CS-11
WQCS00364
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Charles Lee Hornback Work Phone: [phone]
Certificate Type: CS
Certificate Grade: II Certificate #: 993898
Email Address: [e-mail]
Oistely signed by: Chades Hornbeck
Signature: Charles Horn back4C=1J,0r=Envirdnkklnc00 ORCack®envidmkinc Effective Date: 9/4/2024
Ob te: 2024.09.0415:15:35-04'00'
"I certify that 1 agree to my 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: Alvis Keith Pike Work Phone: [phone]
Certificate Type: CS
Certificate Grade: I
Email Address: [e-mail]
Certificate #: 1015140
Oi ifallysignedby:AlvisPike 9/4/2024
Signature: DI\/IC PIMA y CN=Nei. Pike email =apike®envirolinkinccom Effective Date:
n // RA -- .
"I certify that 1 agree to my designation as a Back-up 01 91`dfflHh kWR.i9b9@ 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, 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
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax:[phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone:[phone]
Revised 1112020

Page 2
Facility Name: Rockingham County Collections System Permit#: WQCS00364
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate R:
Email Address:
Signature:
Effective Date:
"1 certify that/ 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
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate R:
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 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 It:
Effective Date:
"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 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
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate If:
Effective Date:
"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 086.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 1112020