WQ0028785_ORC Designation Form_20241010

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Mailing. Address: � QA-__
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Faciiiti Name-�-1CCS��n.�+Cd1.�5s(:Ll4i�lol) Permit it: _...
SUBMIT A SEPARATE FORM FOR EACH "TYPE SYSTEM!
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Biological N'%N'T1' _�c1 � � � Surincc Irti�ntis;n `ZC
Plnsical/Chemical I.nntl Application
Colleciion System
Operator in Responsible Charge (ORC)
Print Full Name: _ rr-,e aa0le-S �Qvi w+•� loaf ( i loo5fo7
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Certificate T3 pe / Grade / Number: r Work Phone #E: Q I0
Signature: 4-Date: - 4S
-1 certtf� 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 W ater Pollution Control System Operators Certification Commission.' ...
.......................................
Back -Up Operalor in Responsible Charge (BU ORC)
Print Full Name: I
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Certificate Type / Grade / Number: t to E Work Phone #: (q!4) i)t. 7 S ,s'Co
r- 55 /pa�r94Y
Signature: �r �,V�— Date: [.D • Q S ' 2 y
-i certify that I agree to my designation as 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 BU ORC as set forth in I SA NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." .......................
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Mai/,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadrninnanrdenr. ov
1E7ail orfax a copy to the Asheville
appropriate Regional Office: 2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone; 828.296.4100
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301.5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2945
Fax: 910,350.2018
Phone: [phone]
\looresr ills
610 £ Center Ave
Suite 30l
Mooresville 28115
Far: 704.663.6040
Phone: [phone]
Winston-Salem
595 W aughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: 919,571.4718
Phone:[phone]
Revised 02.201