NC0071528_ORC Designation Form_20241029

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: DALE NORMAN, LAKE NORMAN WOODS HOA
Email Address: [e-mail]
Permittee Signature: Zak 4)614.1oxC
Facility r ame: LAKE NORMAN WOODS WWTP
SUBMI1 A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: WW-II
Date: lOctober 25, 2023
Permit# NCO071528
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R
.�. �' ,QRC OPERATORINRESPON, IB EaCII%1RGE
Print Full
Name: CRYSTAL RICHARDSON HUTCHENS Work Phone: [phone]
Certificate
Type: WW Certificate Grade: II Certificate #: 1013623
EmailAlddress:
CH [e-mail]
Signature:
Effective Date:
certify that
rules and
43/
I agree to m designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G
Disciplinary
.0204 and failing to do so can result in
Actions by the Water Pollution Control System Operators Certification Commission."
Print FullI
Name: TODD FRANKLIN ROBINSON Work Phone: [phone]
CertificaIte
Type: WW Certificate Grade: IV Certificate #: 989809
Email Address:
TRRROOBIIN/[e-mail]
Signature:
7 a 1
L A4l�r�/+`� Effective Date: T� - 7-1 ~b I
certify that
the rules and
I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G and failing to do
Disciplinary
.0204 so can result in
Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINALto: hEmah,[e-mail] Fax:[phone]
Mail or
a COPY to:
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax:[phone]
Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax:[phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone:[phone]
Revised 1 M020

Facility Name: LAKE NORMAN WOODS WWTP
Print Full Name: KERRY MILLER
Certificate Type: WW
Certificate Grade: I
Email Address: [e-mail]
Permit #: NCO071528
Work Phone: [phone]
Certificate #: 1007587
Page 2
Signature:
Effective Date: /6'e2 9- 0z
"1 certify that 1 agree to my designation as a Back-up 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 OSG .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control system Operators Certification Commission."
Print Full Name: DENNIS MURDOCK
Certificate Type: WW
Certificate Grade: III
Work Phone: [phone]
Certificate #: 7144
Email Address: [e-mail]
Signature: Effective Date:
"1 certify that 1 agree to my designation as a Back-up 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 failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
"1 certify that I agree to my designation as a Back-up 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 Water Pollution Control System Operators Certification Commission."
41 QItC•41,
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"I certify that I agree to my designation as a Back-up 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 failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 112020