WQCS00110_ORC Designation Form_20240930

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation form
NCAC 1SA 8G .0201
TAB to Navigate Form
Facility Name: Town of Clayton Permit # WQCSOO110
Facility Type/Classification: CS 0 Facility Grade: III 0 SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Richard D. Cappola, Jr. PE, MPA, CFM
Email Address: town manager@townofclaytonnc.
Permittee Signature:
ORC
Date:
�C
Full Name: Jason Michael Newman Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: CS 0 Certificate Grade: IV 0 Certificate #: 1004562
Signature: %�Z'_ Effective Date: I ;
'7 certify that 1 agree to my des n tion as the Op atar i Responsible Charge for the facility noted. 1 understand and will abide by the rules and regulations pertaining
to the responsibilities of the O C s set forth in 15 NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
..
Backup ORC
Full Name: James Ernest Blalock Work Phone: [phone]
Certificate Type: CS El Certificate Grade: IV 0 Certificate #: 1002021
Signature: Effective Date: A'S.—InIz
"1 certify that I agree to y deslg anon as the Operator in Responsible Charge for the facility noted, 1 understand and will abide by the rules and regulations per
to the responsibilities oft O 1 as set forth in4T 15A NCAC 08G .0204 and failing to do so can result in DisciplinaryActions by the WPCSOCC"
Backup ORC
Full Name: Travis Milton Jessup
Work Phone: [phone]
Certificate Type: CS 0 Certificate Grade: IV El Certificate #: 1005848
Signature: Effective Date:
"1 certify that) agree to y designatio a Oper ar '�15AfOVCAC
le Charge for the facility noted. l understand and will abide by the rules and regulations
pertaining to the responsibilities RC as set forth in 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: Raleigh-3800 Barrett Dr.,Raleigh, NC 27609 1 FAX: [phone] PH: 919-7914200 El
Use the 2nd page only if you need to list additional Backups.
Revised 0212024

Facility Name: Town of Clayton Permit #: WQCS00110
Backup ORC
Full Name: Stephen Moore Norris, Jr. Work Phone: [phone]
Certificate Type: CS H1
Certificate Grade: IV El Certificate #: 995863
Signature:
Y t Effective Date: 11 O,2
"l certify that 1 agree to my designate n as the Operator in Responsible Charge for io
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 toso con result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Dylan Tyler Carroll Work Phone:
Certificate Type: CS 0 Certificate Grade: IV 0 Certificate #:
011:1114[III:'trf�xl
1010214
Signature: Effective Date:G�
7 certify that !agree y ignotion as the Operator in Responsible Charge for the facility noted. ! understand and will abide by the rules and regulations pertaining
to the responsibilities fbft ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPC50CC'
Backup ORC
Full Name: Stephen Jake Kyer Work Phone: t 1 " �! %_O� 94�
Certificate Type: CS El Certificate Grade: IV El Certificate #: 1011824
f/L� Effective Date: /;o I 4�-
Signature: —
I certify that 1 agree to my designation as the 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 WPC5OCC"
Backup ORC
Full Name: Work Phone:
Certificate Type: Select
Signature:
Certificate Grade: Select
Certificate #:
Effective Date:
"4 certify that 1 agree to my designation as the 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 faith in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Revised 0212024