NC0083119_OIC Designation Form_20241021

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: Coddle Creek Water Treatment Plant
Permit # NCO083119
Facility Type/Classification: WWE Facility Grade: 1 0 SUBMITASEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Lloyd Payne
Email Address:
Permittee Signature:
ORC
Date: A'�) 1Sj/u'Vly
Full Name: Rebecca K Shue Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW EJ1 Certificate Grade: I Certificate #: 1006671
Signature: ::: V �( Z&4 Effective Date: 10/0Y
"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 a d reeg it lr. pertaining
to the responsibilities of the ORC as set forth in 15A NCAC 08G.0204 and falling to do so can result in Disciplinary Actions by the WPC50CC"
Full Name:
Steven Smith
Backup ORC
Work Phone: [phone]
Certificate Type: WW E] Certificate Grade: I Certificate #: 1007520
Signature: = A Effective Date:
"I certify that I agree to my designation as the Operator In Responsible Charge for the facility noted. I understand and will abide by the rules 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:
Certificate Type: Select
Signature:
Backup ORC
Certificate Grade: Select
Work Phone:
Certificate #:
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"
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 0212024

Facility Name: Coddle Creek Water Treatment Plant Permit #: NCO083119
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.
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 falling 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.
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 falling 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 facllfty 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:
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.
I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as setfarth in 15A NCAC 08G.D204 and foiling to do so can result in
Disciplinary Actions by the WPCSOCC"
Rovlsed 0212024