WQCS00372_ORC Designation Form_20241105

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: C���M&.o _ permit#UM,
Facility Type/Classification: CS Facility Grade: II SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name:
Email Email Address: C1`flo�1P�i
Permittee Signature:
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Full Name: C%� Work Phone:
Email Z - tl—§� a- j(N:5 k sac Qth&—
Certificate Type: CS Certificate Grade: II Certificate #:ffiwa
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Signature: Effective Date:
I certify that I agree to my design6otion 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 failing to do so can result in Disciplinary Actions by the WPCSOCC'
Backup ORC
Full Name: Work Phone:
Certificate Type: CS Certificate Grade: I Certificate #:
Signature: bEffective Date: I' l I 1 N
I certify that I agree to my signation as tQ9perator 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 WPCSOCC
Backup ORC
Full Name:
Certificate Type: Select
Signature:
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. 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'
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: Raleigh-3800 Barrett Dr.,Raleigh, NC 27609 1 FAX: [phone] PH: 919-791-4200
Use the 2nd page only if you need to list additional Backups.
Revised 0212024