WQCS00237_ORC Designation Form_20241008

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: Town of Princeton
Facility Type/Classification: CS 3 Facility Grade: II
Permittea nuunar/nffirar Noma- Michael King
Email Address: m.king rincetonnc.com
Permittee Signature:
Permit # WQCS00237
0 SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Date:_101elzp2c�.
ORC
TM 9/9- -2�IZ
Full Name: Sanders Work Phone:
Email Address: [e-mail]
Certificate Type: CS 19 Certificate Grade: II El
Certificate #: 1015205
Signature. 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 WPCSOCC"
Backup ORC
Full Name
Ervin Glenn Holland
Work Phone: [phone]
Certificate Type: CS Certificate Grade: IV Certificate I#: 24248
Signature: Effective Date: /Q � L
"I certify that I agree to my designation as the Operator kr Responsible Charge for the facility noted. I understand and will abide by the tales 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 WPC5OCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature: Effective Date:
"9 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"
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 13
Use the 2nd page only if you need to list additional Backups.
Revised 0212024