WQCS00068_ORC Designation Form_20240916

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: SOUTH GRANVILLE WATER AND SEWER AUTHORITY Permit # WQCS00068
Facility Type/Classification: CS
Permittee Owner/Officer Name:
Facility Grade: III SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
.5,-0 i' A,-. scy"rec--
Email Address:
Permittee Signature: Date: 17-1-17
ORC
Operator in Responsible Charge
Full Name: Robert S. Jackson
Email Address: rjackson@sgwasa.
Work Phone: �/9 603- H%Q
Certificate Type: CS Certificate Grade: IV Certificate #: 1002398
Signature: Effective Date:
"I 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"
Backup ORC
Full Name: oe.l M ick el C.Q0 s Work Phone: q19- 38y— SS/7
Certificate Type: C s Certificate Grade: oZ Certificate #: /d / 3ylo8
Signature: Effective Date:
"/ certify that I agree to 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 WPCSOCC"
� p Backup ORC
�n
Full Name: Vvlllioyyl 31 -6ctn W uey- Work Phone: qj& 1 - 3?j
Certificate Type: C -5Certificate Grade: 2 Certificate #: 10 1 3 %2 ZS
Signature:AL�,,Effective Date:
"I certify that 1 agree to signotion 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]
G�
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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 1112023