WQ0012690_ORC Designation Form_20240923

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Robert McGraw, NC-DPR
Email Address: [e-mail]
Permittee Signature: �� i" Date: / z J Z �L
Facility Name: Mt. Mitchell State Park WWTP Permit # WQ0012690
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SI
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: David Aaron Rogers Work Phone: _ [phone]
Certificate Type: SI Certificate Grade: Select Certificate #: 1015349
Email Address: [e-mail]
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Signature: David Rogers-RMN-k.'­t_d°°° ®°c=ego Effective Date: 9/20/2024
- EmIM!nk W 6w W- ORC
"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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Todd Franklin Robinson Work Phone: [phone]
Certificate Type: SI Certificate Grade: Select Certificate #: 1006252
Email Address: [e-mail]
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Signag Todd Robinson US0=Erhl�k.Im �tl- ftbftw� �� �- Effective Date: 9/20/2024
ture: �Ba=EnviraWnk Inc.
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 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."
Mail, fax or email
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville
2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 1112020

Page 2
Facility Name: Mt. Mitchell State Park WWTP Permit #: WQ0012690
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"I certify that I 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 failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate M
Email Address:
Signature:
Effective Date:
"1 certify that I 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 failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"i certify that I 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 ISA 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: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate M
Effective Date:
"I certify that I 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 failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 1112020