WQ0003271_ORC Designation Form_20240917

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A sG .0201
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Facility Name; Hestron Park
Permit # WQ0003271
Facility Type/Classification: WW 3 Facility Grade: Il SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Carolina Water Service, Inc. of NC 1 Tony Konsul
Email Address: tony•[e-mail]
Dlgltally slgnetl by Tony Konsul
OU='Vice Presitlent Operations', O=Carpllna Wader
e °l Nm, CN=Tony Nensul, E= y pnsul@
Permittee Signature. TOny KonS ' 9 „„ °a ,betl°a°men
Da�e�114024.00",T 09;483&Oh'00'
Date.-
ORC
Full Name: Samuel Cox Work Phone: (252) 808_7676
Email Address; samueI.Cax nexusw .com
Certificate Type: WUV—_ L7J Certificate Grade: 11 _
Certificate #: 1011296
M.
Signature;
I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted.
Effective Date:
I
understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in Z5A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC-
Backup ORC
Full Name: Hob
Work Phone: [phone]
Certificate Type: VUV11 _ Certificate Grade;
Certificate #: 1015374
Signature:
Effective Date:
"i certify that' agree to nay designation as the Operator in Responsible Charge forthfacility
to the responsibilities of the ORC as set forth in TSACAC 0SG noted, 1 understand and will abide by the rules and regulations pertaining
fU.0204 and failing to do so
can result in
Disciplinary Actions by the wpcsocc,
Backup ORC
Full Name: Stacy Got
Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV
__...__
Certificate #: 998882
Signature: �� 4'��
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 and failing
.02p4 to do so can
result in Disciplinary Actions by the WPCSOCC"
Ernail this form to: [e-mail],gov
AND
Send to your DEQ Regional Office (send to your contact or find ernails 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 aMy if you need to list additional Backups.
Revised 02/2o24