NC0050792_ORC Designation Form_20241105

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A SG .0201
TAB to Novigote Form
Facility Name: MELBILLE HEIGHTS Permit 0 NCO050792
Facility Type/Classification: {NW Facility Grade: II SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Pennittee Owner/Officer Nam ^qua North arolina/Tyler Hester
Email Address: t'h er aqua
Permittee Sigrr3ture• y
Date: v
ORC
Full Name: Justin Allen Stein Work Phone: [phone]
Email Address: )astein(cDaquaarnerica.com
Certificate Type: WVV Certificate Grade: I) Certificate#: 1013645
I
Signature: _ ~ Effective Date:
"I certify that I agree to my des ouon os 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 Disciphnory Ar:inns by the wPCSOCC-
Backup ORC
Full Name: Donte Lamont Campbell Work Phone: [phone]
Certificate Type: VVW_- Certificate Grade: IV Certificate#: 1014158
Signature: T E Effective Date: 70 -2 t __
"I certify that I agree to my designation as the Operator Responsible Charge for the facility noted. 1 understand and will obide by the rules and regulations pertoining
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: Samuel E Pegram Work Phone: [phone]
Certificate Type: 1NVIl Certificate Grade: ll Certificate#: 11008
Signature: Effective Date: - ' �-
"I certify that t agree to my designation as the Operator In Responsible C rge for thelocnity noted. t understand and will abide by the rules and regulations
pertmning to the responsibilities of the ORC asset forth to 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: Chooso DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Rn�uod 02:01,r

Facility Name: MELBILLE HEIGHTS Permit#: NCO050792
Backup ORC
Full Name: Peter Ray Dealing Work Phone: [phone]
Certificate Type: WW Certificate Grade: II Certificate#: 997449
��� .J
Signature: - X ZC'D Effective Date:
"I certify that I agree to my designation as the O "tar
in Responsible Charge for the fa ility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in 5A NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Richard Earl Mcfadden Jr Work Phone: [phone]
Certificate Type: WW Certificate Grade: III Certificate M 1015877
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.0104 and foiling to do so con result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Shelby Darlene Cheek Work Phone: [phone]
Certificate Type: WW ficate Grade: III Certificate#: 996309
Signature: Effective Date: L� V
"I certify that I agree to my esignatio s the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and regulation pertaining
to the responsibilities of the ORC as forth in 15A NCAC 08G.0104 and failing to do so con result in Disciplinary Actions by the WPCSOCC"
Backup OR
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 asset forth in 15A NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Revised OZ/2024