WQCS00137_ORC Designation Form_20241014

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: CITY OF SOUTHPORT COLLECTION SYSTEM
Permit # WQCS00137
Facility Type/Classification: CS Facility Grade: II SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: John Nichols
Email Address: john.nichols(�D_brunswickcountvnc.aov
Permittee Signature:
ORC
Date:
Full Name: John Gregory
Work Phone: [phone]
Email Address: 1ohn.gregorybrunswickcountync. ov
Certificate Type: CS - Certificate Grade: IV
Certificate #: 1005528
Signature-
Effective Date:
"I certify th agree to designation as the Operator in espon ' le Charge for the facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of he 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: Michael Caison
Work Phone: [phone]
Certificate Type: CS Certificate Grade: IV
Certificate #: 994299
a
Signature: i�,i'acrw �
----J�/ �V/c
Effective Date:a��
"1 certify that l agree to my designation as the Operator in Responsible Charge for the facility noted.
l 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: Isiah Randolph
Work Phone: [phone]
Certificate Type: CS Certificate Grade: IV
Certificate #: 995598
Signature: Effective Date: /' Q U
"1 certify that I agree to my d ignation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and regulat ons
pertaining to the responsib 2 Mies of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can 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: - - -
Wilmington-127 Cardinal Dr., Wilmington, NC 28405-2845 1 FAX: [phone] PH: 910-796-7215
Use the 2nd page only if you need to list additional Backuns_

Facility Name: CITY OF SOUTHPORT COLLECTION SYSTEM Permit #: WQCS00137
Backup ORC
Full Name: Bobby Faircloth
Work Phone:
[phone]
Certificate Type: CS Certificate Grade: IV
Certificate #: 992244
Signature:
Effective Date:
"I certify that I agree to my designation as the 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the WPCSOCC"
Backup ORC
Full Name: Kerich Randolph
Work Phone:_ [phone]
Certificate Type: CS Certificate Grade: III
Certificate #: 1012720
Signature: - Y
Effective Date: ty . -t -;z ,
"l certify that I agree to my designation as the Operator in Responsible Charge for the facility noted.
to the responsibilities of the ORC as set forth in 15A NCAC 08G
I understand and will abide by the rules and regulations pertaining
.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"1 certify that I agree to my designation as the 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 set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
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 the Operator in Responsible Charge for the facility noted.
to the responsibilities of the ORC as set forth in 15A NCAC 08G
I understand and will abide by the rules and regulations pertaining
.0204 and failing to do so can result in
Disciplinary Actions by the WPCSOCC"