WQCS00109_ORC Designation Form WQCS00109_20241021

11. CS T!.. ala C-1% 4710-
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ihlator P0lllJti0r1 C;ohtrol 4;Vrfom OPERATOR IN IMF&I}i' NSIRLE w HARfsl~ (C71Rr) norign;ktiryr' FnrM
NCAC 15A SG .0201 OCT 2 1 20M
TAB to Nawyate Form
facility Name: TO1r'°JN OF BENSON Permit, ___.-m—C16§80M —
Facility Type/Classification: .+ 5::::: Facility Grade: fI SUBMIf A SEPARATE PoRm FOR EACH C1.AS51FIC TION
Permittee Owner/officet,Nanie: Ttaw,ln of Beason I Kimberly Pickett
Email Address
Permittee Slgnat
kpickett(otowhofbenson. coon
Date: t� �t.'i.�-z -$
��2aiuiAK4Riy."�'a�.q�.:.�,RTfi�7.0.Ct,�.,�..._ill'�'w':�-.�'i'f�iCi9ph+'t''.. serve. -.. -�.e .�au.�e.:+.: rs.m n.:.vasxwo... '.�', ib:�Siu:ax�i3,.+-ri3'fi1L-.irf.:E'h�F•..-'r'W�m.ren.�-ti•-.-titi:..:xr••dban-'x+-��.dme:?'..+�.r-.. t L'...V
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Full Name: Jeremy Bryant Work'Phone: [phone]
Email Address: jbr\jant a@ town ofbensori.com --_--- —
Certificate T CS Certificate Grade: II Certificate 14: —� 1008926
Signature: r'�-� T—Cffectivt='Date:^ tot.4 Iw
"I certify that 1 agree tk<y designuiion as M.e Opurotc n Responsible Charge for fhe fvcility noted. 1 timlerstord and wif1 abide by the rules and 'regulations puitalning
to the responsih lities of the ORr as set forth in .[aA N(fAC MG ;M4 and falling fAdo So cap result in Disoplinory Actions by the MIC:OCC"
Backup ORO
full Name: .Andrew Alan Cain Work Phone: (:919) 594-3553
Certificate Type: CS _ Certificate Grade- - �I . Certificate H:_. 1015191
Signature- �__. - �~- G'`— �`` `� `---Fffective Date:_ r r' t`t %'IF
"! certify Mot l agree to my desigrratrop as the operotor in Responsible Ch,rrae fa: file facility nared, i understundrind MY abide by aie rules and reguiations perroining
to the responsibilitiesofthe ORC us set forth In 15A JNCAC 08G .G1G4 and; ailing to do so can result in o&cipRiror;' Actlens by the 411MOCC"
Backup (--;RC
Full Name: D Rev Adams Jr Work Phone: [phone]
Certificate Type: Select Certificate G-radc: Select1000968- -
.. J Certificate #:
Si4natUle: ! i i1 {�''_Effective Date:
"! crrtify'that rarer t't my desigttriti-M its the operdtor it Rqsons; hre Durgc for the f acility na ed. 1 unders4asrtf and x iir abide by the rules OM regtt/tirrons
pe, Coming f a the respcnslirtTrles of the GRC us sel for'.'. in 13A AiCAC 438G .0204 and fodrno to dose car, rest it i.l Disciplinary Actiaru by the WPCSOCC'r
Erriali this fnriri to: [e-mail],gov
AND
Cann *n c:nrr: f5r[-f_►ccgint��l rlf¢ir-ro fea'~ri Tnuh �r ^riniari rsr finri �rri:i' c hnrntivWw r{Prt nr.tit3V/RhntfS![:tlritelCtfrF.£Iflnal-OffICES
or fax using u�i5 drop down list: Raleigh-3800 Barrett D,.Ra:eigh, NC 276091 FAX: [phone] PH' 919.-79-1-4200
Use the 2-.d pane only ii you need to list addit;onal B,:M(,-ps.
Re+tssd Ge2r-,02 3