WQCSD0090_ORC Designation Form_20240910

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAR to enter information
Permittee Owner/Officer Name: Marty Parnell
Mailing Address: PO BOX 9 Phone:
City: Micro State: NC Zip:
Email Address: [e-mail]
Signature:
Facility Name: Micro ollection System
County: Johnston
[phone]
27555
Date: ij- 3 - Z e zq
Permit # WQCSDO090
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
SEP -6 2074
Facility Type: CS []
Facilitv Grade: I 0
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: _Walter Kenneth Wall II Work Phone: [phone]
Certificate Type: CS 0 Certificate Grade: Certificate #: 1014348
Email Address: [e-mail]
Signature: Date:
"7 certify that l agree to my designation as the Operator in Responsible Charge for the facility noted l 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: Jason Lee Banks Work Phone:[phone]
Certificate Type: CS 0 Certificate Grade: I
Email Address:
icro.com
0 Certificate #:1015139
Signature: Date: 4q' 3 -2 Y
"1 certify that 1 agree to m Kertailning
gnation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will abide by
the rules and regulations 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, Fax: [phone] Email: [e-mail]
ORIGINAL to:
Raleigh, NC 27699-1618
Mail or Fax
Asheville
Fayetteville
Mooresville
Raleigh
a COPY to:
2090 US Hwy 70
225 Green St., Suite 714
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Swannanoa, NC 28778
Fayetteville, NC 28301 5043
Mooresville, NC 28115
Raleigh, NC 27609
Fax: [phone]
Fax: [phone]
Fax- 704-663-6040
Fax: [phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Ltd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Revised 412016

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