WQCS00361_ORC Designation Form Davidson County_20241030

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Davidson county sewer system Permit #
WQCS00361
Facility Type/Classification: Select Facility Grade: Select SUBMiTA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Dylan A. Lambeth for Davidson county Government
Email Address: [e-mail]
Permittee Signature: `�''/ Z!-A-0 Date:
ORC
Full Name: Dylan A. Lambeth Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: CS 0
Certificate Grade: I El
Certificate #: 1013412
Signature: 1 -1 1 ��Allwll + Effective Date:
"1 certify that l agree to my designation as the Operator in Responsible Charge for the facility noted. ! understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Full Name
Steven Sink
Backup ORC
Work Phone: [phone]
Certificate Type: Sl 0 Certificate Grade: I 0 Certificate #: 1015109
Signature: i& Effective Date:
"l certify that l agree to my designation as the Operator in Responsible Chorge 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: Charlie A. Brushwood Work Phone:
Certificate Type: CS 0 Certificate Grade: 11 0 Certificate #: 999522
Signature: / Effective Date: QZTA
"l certify that I agree to y designation as the Operator in Responsible Charge for the facility noted 1 understand and will abide by the ru! and regul trans
pertaining to the res nsibilities of the ORC as set forth in 15A NCA C 08G .0104 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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised OW024

Facility Name: Davidson county sewer system Permit #:
Full Name:
Certificate Type: Select
Backup ORC
Certificate Grade: Select
Work Phone:
Certificate M
WQCS00361
Signature: Effective Date:
"i certify that 1 agrrr 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 rrsponsibXties of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Full Name:
Certificate Type: Select
Backup ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"1 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 asset forth in 15A NCAC 086.0204 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:
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 asset 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:
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 ISA NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Revised 0212024