NC0077763_ORC Designation Form_20220407

RECEIVED/NCDEO/DWR
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POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FOR
NCAC 15A 8G .0201 MOORESVILLE REGIONAL OFFICE
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Facility Name: City of Belmont Permit# NCO077763
Facility Type: PC 0 Facility Grade: I F-1 SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Adrian Miller
Email Address: amiller cit ofbelmont.or
IlPermittee Signature: 9L(Qe;—F e Date: 4/1/22
ORC
Operator in Responsible Charge
Full Name: Jennifer Gibson __ Work Phone: [phone]
Email Address:
Certificate Type: PC Certificate Grade: I 0 Certificate#: 1011580
Signature: Effective Date: - ' n 2
"1 cer'f hot I agree.to y 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 OSG .0204 and
failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Timothy Robinette Work Phone: [phone]
Certificate Type: PC Certificate Grade: Certificate#: 1007123
Signature: 4 'V^n ii<- . �� i Effective Date: l ( - I - )C
"I 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
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate#:
Signature: Effective Date:
"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 as set forth in 15A NCAC 08G.0204 and foiling 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,NC 27699-1618 1 FAX:[phone] [e-mail]
Mail or fax a COPY to: Mooresville-610 E.Center Ave., Suite 301, Mooresville, NC 281151 FAX:[phone] PH: 704-663-1699
Revised 312019