WQCS00364_ORC Designation Form_20240909

WATER POLLUTION ::ONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
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Permittee Owner/Officer Name: Rockingham County c/o Ronnie Tate
Email Address: [e-mail]
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Permittee Signature: _ — Date:
Facility Name: Rockingham County Collections System Permit # WQCS00364
SUBMIT A SEPARATE FORM FOP EACH SYSTEM CLASSIFICATION: CS -II
_ ORC - OPERATOR IN RESPONSIBLE CHARdE
Print Full Name: Charles Lee Llornback
Certificate Type: CS
Email Address: Ch
Signature:
Certificate Grade: II
Work Phone: [phone]
Certificate #: 993898
Effective Date: 9/4/2024
"I certify that 1 agree idmy 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 Pollu'ion Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: AIVIs Keith Pike Work Phone: [phone]
Certificate Type: CS
Email Address: ap
Signature:
Certificate Grade: I
rolinkinc.com
Certificate #: 1015140
Qs,s . t-1 L. Effective Date:
9/4/2024
"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 Pollu'ion Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 161.8 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Email: ceitart [e-mail],- Fax:[phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
2090 US H'Ny 0 225 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:828-;196-4500 Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, kC 27889
Fax: [phone]
Phone: 25 9,16-6481
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