NC0020389_ORC Designation Form_20240913

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
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Facility Name: BENSON WASTEWATER TREATMENT FACILITY Permit # NCO020389
Facility Type: WW Facility Grade: IV SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Kimberly Pickett
Email Address:
Full Name: Brian Peter Leavitt Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV _ Certificate #: 1007659
Signature: _ Effective Date:_ 4"(4/Ly
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 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."
Full Name: Steve A. Procter Work Phone: [phone]
Certificate Type: WW /� Certificate Grade: IV Certificate #: % 26527
Signature: Effective Date:
d r
I certify that l 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 I FAX: [phone] Ice rtait min@ncden r.gov
Mail or fax a COPY to: Choose DWR Regional Office that has coverage of this facility.
Revised 312019