NC0085812_ORC Designation Form_20240924

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Grassy Branch WWTP Permit # NCO085812
Facility Type/Classification: WW R Facility Grade: 11 F71 SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Union County Water / Jonathan Jordan
Email Address: Jonathan.jordan@un
Permittee Signature:
1
7
ORC
Full Name:
Email Address:
Certificate Type: Select
Certificate Grade: Select
Date:
Work Phone:
Certificate #:
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: Patricia Lee Myers
Certificate Type: VVW _.__ 0 Certificate Grade: _
Work Phone: [phone]
Certificate #: 1015827
Signature: - � _Effective Date: _Cj
"I certify that i agree to my designation as the OperatOin 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:
Certificate Type: Select Certificate Grade: Select
Work Phone:
Certificate #:
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 asset 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]
GNED
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 0212024