NC0046892_ORC Designation Form_20241001

WATER POLLUTION CONTROL SYSTEM OPERATOR DESiIGNATION FORM
NCAC 1SA 8G .0201
TAB to Navigate Form
Facility Name; GLOBAL COMPANIES CHARLOTTE SOUTH TERMINAL Permit # NCO046892
Facility Type: PC Facility Grade: I SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Tom Keefe
Email Address: [e-mail]
Permittee Signature: Date: 10/01/24
iiloocoe�'
ORC
Operator in Responsible Charge
Full Name: Colin Parker Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: PC Certificate Grade: I Certificate #: 996745
Signature: Effective Date:
"1 certify that 1 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: Justin Baker Work Phone: [phone]
Certificate Type: PC Certificate Grade: _ I Certificate #: 1002045
Signature: Effective Date: 30 2oa
i certify t I agree to my designate n as a Back-up pe r in Responsible Charge for the facility noted. I understand and will
a i e y 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
Backup ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
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 setforth in I5A NCAC 08G.0204 and failing to do
so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
Mail, fax ore mai 1ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 I FAX: [phone] l [e-mail]
Mail or fax a COPY to: � Raleigh-3800 Barrett Dr., Raleigh, NC 27609 l FAX: [phone] l PH: 919-791-4200
Revised 3/2019

Facility Name: GLOBAL COMPANIES CHARLOTTE SOUTH TERMINAL Permit #:
Backup ORC
NCO046892
Page 2
Full Name:
Work Phone:
Certificate Type:
Select Certificate Grade: Select Certificate #:
Signature:
Effective Date:
"I certify that / 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 falling 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 It:
Signature:
Effective Date:
"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
Full Name:
Work Phone:
Certificate Type:
Select Certificate Grade: Select Certificate It:
Signature:
Effective Date:
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 os set forth in 15A NCAC 08G .0204 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 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 06G.0204 and falling to
do so can result in DisciplinaryActions by the Water Pollution Control System Operators Certification Commission."