WQ0021934_ORC Designation Form_20240925

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Aqua North Carolina/Lorraine Stagner
Mailing Address: 202 Mackenan Court
City: Cary
Email Address:
Signature:
Facility Name: Hasentree
County: Wake
[e-mail]
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Phone: [phone]
State: NC zip: 27511
Date:
Permit # WQ0021934
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
f Facility Type: WW _
,Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Patrick Casey Work Phone: [phone]
Certificate Type: WW Certificate Grade: II Certificate #: 1003251
Email Address: PMCasey@[e-mail] _
Signature: _ Effective Date: �� L — 7—
"I certify that I agree to my designation as the Operat 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."
[� BACKUP ORC
Print Full Name: Michael Till Work Phone: [phone]
Certificate Type: WW
Email Address: [e-mail]
Certificate Grade:
Certificate #:1015802
Signature: 70; I VV"' 2!�_ _ Effective Date: I'Zt1 / Of
"I certify that 1 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 WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
Raleigh
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Mooresville, NC 28115
Raleigh, NC 27609
Fax: [phone]
Fax: [phone]
Phone: [phone]
Phone, 919-791-4200
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone] Rev -'Zed 412916