NC0085839_OIC Designation Form_20241027

Water Pollution Control System ORC Designation Form
WPCSOCC
NCAC 15A:08G .0201
Permittee Owner/Officer Name: Sibelco North America — Red Hill Facilit • / Kevin Wilson
Mailing Address: —Post Office Box 588
City: S�-ruce Pine State: NC Zip: 28777 - Phone #: (8_28) 537-1819
Signature: Date: /G .2 6 V
Facility Name: Sibelco North America. Inc. — Red Hill Facilit_ Permit #: NCO085839
SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM!
Facility Tyne/Grade:
Biological WWTP Surface Irrigation
Physical/Chemical 2 Land Application
Collection System
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Operator in Responsible Charge (ORC)
Print Full Name: Jason Clark Willis
Certificate Type/Qrpde/Number. P / Grade 11 / ????????� Work Phone #: (aL8) 688-2169
Signature: f Date: 10 12 2
"I certify that I a , � 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 esponstbilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
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Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: i ��_ G {,�
Certificate Type/Grade/Number: to Z �� { ���0 Work Phone #: VS
Signature: 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'r6ponsibilities of the ORC as set forth in I SA NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
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Mal4 fax or email the original to: wPCSOCC,1618 Mail service
Center, Raleigh, NC 27699-1618 Fax:
919.907.6492
Mail or fax a copy to the
appropriate Regional
Office:
Emall: certadmin(a@,nedenr.gov
Asheville
2090 US Hwy 70
Swannaim 28778
Fax: [phone]
Phone: 828.2%.4500
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone:[phone]
Fayetteville
Mooresville
Raleigh
225 Green St
610 E Center Ave
3800 Barrett Dr
Suite 714
Suite 301
Raleigh 27609
Fayetteville 28301-5043
Mooresville 28115
Fax: 919.571A718
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: 336.771A631
Phone: [phone]
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Revised 02-2013