NC0020737_ORC Designation Form_20241107

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Farm
Facility Name: Pilot Creek WWTP
Permit # NC0020737
Facility Type/Classification: VM Facility Grade: IV SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Ricky Duncan
Email Address: [e-mail]
Permittee Signature:
Date: r ' 26 Z
ORC
Full Name: Ricker Lee Bailey Work Phone: [phone]
Email Address: lee. [e-mail]
Certificate Type: WW El Certificate Grade: IV Certificate #: 998086
Signature: Effective Date: J.1- ) - 2 a q
"I certify that I agree to my designation as the Operator in ResPonsiblelarge 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 A204 and failing to do sa can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Kevin Hodges Work Phone: [phone]
Certificate Type: WW a
Signature: I le_
Certificate Grade: IV a Certificate #: 20151
Effective Date: !f - ? - a, L
! certify that l agree to my designation as the Operoto Responsible Ch rge 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 ISA NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: Daniel Wimpey Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: II! Certificate #: 1015499
/ F
Signature: Jf/!// Effective Date:
certify that !agree to4mydesignation as t0�jbletor in ResponsCharge for the facility noted. 1 understand and will abide by the rules and regulations
pertaining to the responsibilities of the O rth 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: Mooresville-610 E. Center Ave_, Suite 301, Mooresville, NC 28115 i FAX: [phone] J PH: 704-6EE
use the 2nd Page only if you need to list additional Backups.
Revised o2/2o24

Facility Name: Pilot Creek WWTP
.n��
Backup ORC
Permit M NCO020737
Full Name: Karyn Hoggard
Work Phone: [phone]
Certificate Type: WW Certificate Grade: III El
Certificate #: 1015885
Signature:
Effective Date: ji 11111f
"I certify that 1 agree to my designpffillp
Oerator in Responsible Charge for the facility noted. 1 understand and will abide by the rules and regulations pertaining
to the responsibilities of the OR s set h in 5A NG4C08G.0204 and failing to do so can result in Disciplinary
Actions by the WPC5OCC"
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.
to the responsibilities of the ORC as set forth in IBA NCAC 08G
I understand and will abide by the rules and regulations pertaining
.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:
certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted.
to the responsibilities of the ORC as set forth in 15A NCAC 08G and failing to do
1 understand and will abide by the rules and regulations pertainrng
.0204 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:
1 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 da so coo result in Disciplinary Actions by the WPCSOCC"
Revised 02/2o24