WQCS00109_ORC Designation Form_20241015

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Farm
Facility Name: TOWN OF BENSON
Facility Type/Classification: CS-. Facility Grade: II,.-
Permittee Owner/Officer Name: Town of Benson / Kimberly
Email Address: [e-mail]
Permit # WQCS00109
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Pickett
Permittee Signatr C, l`-CA Date: 10 111il2'i
ORC
Full Name: Jeremy Bryant Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: CS
Certificate Grade: 11
Certificate #: 1008926
Signature: Effective Date: to 1 l4 1y,y
"1 certify that I agree t y designation as the Operota>n 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 WPCSOCC"
Backup ORC
Full Name: Andrew Alan Cain Work Phone: [phone]
Certificate Type: CS Certificate Grade: II Certificate #: 1015191
Signature: Effective Date: I o) ly `M. s
"I certify that 1 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"
Full Name
D Ray Adams Jr
Certificate Type: Select
GM, - R
Work Phone: [phone]
Select Certificate #: 1000968
Signature: lti`ll, V. A/'' Effective Date: J0 6'/ z4
"I certify that I agree to my designation as the Operator in Rg onsible Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibilities of the ORC os set forth in 1t A NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Email this form to: [e-mail]
mug
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 I Raleigh-3800 Barrett D[.,Raleigh, NC 27609 1 FAX: [phone] PH: 919-791-4200
Use the 2nd page only if you need to list additional Backups.
Revised 0212024