NCG590018_ORC Designation Form_20241002

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A SG .0201
TAB to Novigote form
Far..ility Name: Southern Pines Water Treatment Facility w^ _ Permit # O 1
Facility Type/Classification, PC 13 Fadi"sty Grade: I Ej SURANT A gDS AiZATE FORM FOR FACH CWSIFICAMPI
Permittee Owner/Officer Name: Town 4i5outber1 Pines ! Ron Istre, Utilities Su re_jcndent
Email Address: ri5tre@sotrthe
POrrllittee 5ignataT@;
ORC
es.net
Date: 9/24/24
Fuif game: David- A. McKee — — — -- _ -- Work Phone: (9iA} 281-4719 - —
Email Address: DUVld.TrkeWCVe¢Iia.Com — � -- --- -- -- _ _
Certificate Type: EC._, [a Certificate Gracie; -1 - a Certificate #. — 991233
Itt
Signature. I ,, t-1 , Effective pats:
certify chat I agree to my desftrlratron os trte Operotarin Re.Toalbte Chorge for the facrlfty noted. I understood and wflf UAide by the roles and regtNattons pertoining
to the resAotysibifltles of the ORC as set forth In I5A NCAC 08G -0204 and fdliRg is try saran resort in aJSctplfnary ACtians by the WFCSOCC"
Backup ORC
Ftsti Name: Ryan Porkins — — — ._w � � VV0fk Phone. [phone]
PC 1 4:9 Certificate #1 �L� /
Certificate Type: — . C ertifieate �rede: _- -- --- ._-.
SignOture:� —� _ __ — ryEffeceive Date:—
JI certify that I agree to my dislgnotlar3 as the 0yw0tor in Rew06sih1e ChvQ]c,far thr foe lity noted J urrderstond Lod will abide by the rufes andTege+Intior $ �lartoining
to the respoAsibilftfes.af the ORC as serjarth it; 15A NCAC 08G.02Cfa oncifniring ro do so ran resort rn b$cipf,irary Acrlans by the WPCSOW
Fuli Marne:
Certificate "Type: SeleCt
5ignatt,lre:
Backup ORC
Work Phone:
Certificate Grade: Seietn Certificate #:
Effective Date:
"I ref(dy that f agree Corny dRF1gn0tl4Ln as Oft OpRraWW Respansrbfe ChQrge for thejaciJfiy noted. l undcrsfond pod wffl ohfdt by the ruks andregrlfations
nertalrting to the responstbifftfes of the ORC os set forth rn iSA NCAC 080.0204 and offing to do so can resuk in Visriplinary Actions by the WKSOCC"
Wail this forth to: [e-mail],90V
AND
Send to your DEQ Regional Office (send to your contact or find emaiis here, www.deq.nc,gcw/about/colitact/rt?gional-offir:es
or fax s raI (': �y *ille-225 Greer, St., Sua(e 714, Fayettevl le, NC 28301.60431 FAX' 940-486-0701 i phi. 910-4a
Ct '
SEP21 2024 uw tha ?rid Pose o* if you need to 45t odd[ttonal Batkilps.
Ros4402/2024
!)EG-FAYETTEIIILLE REGIONAL
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