NC0078271_ORC Designation Form_20241003

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Betsy -Jeff Penn 4H Educational Center Permit #
Facility Type/Classification: WW Facility Grade: 1
Permittee Owner/Officer Name: NC State University
NCO078271
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Email Address: [e-mail] , S-�acV — UCAS(g ASO :Lk . e-dLk
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Permittee Signature: , � Date: r
ORC
Full Name: Ethan Beaver
Email Address:
[e-mail]
Work Phone: [phone]
WIN Certificate Grade: I Certificate #: 1015835
Certificate Type: C
Signature:
Gil `�02Effective Date: / Q / I / � [
'I certify that I agree to my designation as the O erotor in Res onsible 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 5A NCAC 08G .01 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Glenn Pullman Work Phone: [phone]
Certificate Type: WW Certificate Grade: I V Certificate #: 992883
Signature:
�%,,,` ��` Effective Date: /6 / ( f z el
'i certify that i agree to my designation as the Operator in Responsible Charge for thefocility 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 WPCSOCC'
Backup ORC
Full Name:
Certificate Type: Select Certificate Grade: Select
Signature:
Work Phone:
Certificate #:
Effective Date:
"I 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 I5A NCAC 08G.0.204 and failing to do so con 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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 0212024