NC0024112_ORC Designation Form_20241001

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
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Facility Name: HAMBY CREEK WASTEWATER TREATMENT PLANT Permit # NCO024112
Facility Type: WWQ Facility Grade: IV n 3uBMITASEPARATE FORM FOR EACH CLASSIF!CATION
Permittee Owner/Officer Name: Michael Brandt
Email Address: [e-mail]
Permittee Signature:Date: % OS" L_
ORC
Operator in Responsible Charge
Full Name:
Email Address:
Work Phone:
Certificate Type: Select Q Certificate Grade: Select Q Certificate #:
Signature: Effective Date:
"1 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 Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Michael Jess Hutcheson Work Phone: [phone]
Certificate Type: WW F] Certificate Grade: IV � Certificate #: 1012912
Signature: �le<l��ir�a�ers l Effective Date: Q OS
"1 certify that I agre to my designation as a Back-up Operator in Responsible Charge for the facility noted I and stand 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."
Full Name:
Certificate Type: Select
Signature:
Backup ORC
Certificate Grade: Select
Work
Certificate
Effective Date:
"9 certify that i agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: [phone] [e-mail]
Mail or fax a COPY to: Choose DW R Regional Office that has coverage of this facility.
Reifsed312019

Facility Name: HAMBY CREEK WASTE WATER TREATMENT PLANT Permit #:
Full Name:
Certificate Type: Select
Signature:
Full Name:
Backup ORC
NCO024112
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
Page 2
"I certify that I agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
Backup ORC
Certificate Type: Select Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"I certify that I 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."
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"1 certify that I 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 .0104 and failing to
do so can result in DisciplinaryActions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature:
Effective Date:
I certify that 1 agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."