NC0069523_ORC Designation Form_20240924

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
Facility Name
Tallwood Estates WWTP
NCAC 15A 8G .0201
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Permit # NCO069523
Facility Type/Classification: WW 0 Facility Grade: II 0 SUBMiT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Union County Water / Jonathan Jordan
Email Address: [e-mail]
Permittee Signature: Date:
ORC
Full Name:
Email Address:
Certificate Type: _Select
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"I certify that / 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 Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade:.0 Certificate #: 1015827
Signature: :LA= 0-k_�
^—Effective Date: q"d'3'aq
s
"l certify that I agree to my designation as the Operator in possible 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 V/PCSOCC"
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 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