NC0069841_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: Crooked Creek WWTP #2 Permit # NCO069841
Facility Type/Classification: WW n Facility Grade: III 0 SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Union County Water / Jonathan Jordan
Email Address: [e-mail]
Permittee Signature: ®��� 'Z" Date:
ORC
Full Name:
Work Phone:
Email Address:
Certificate Type: Select Certificate Grade: Select
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: Amy Rosa Molina-McCarley
Work Phone: [phone]
Certificate Type: WW Certificate Grade: _11_____
Certificate #: 1015863
Signature:j!��_ _ ______
Effective Date:
"I certify that i agree to m4dlignation as the Operator in Response 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 WKSOCC"
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
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"
Email this form to: [e-mail]
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 0212024