WQ0018755_ORC Designation Form_20241108 (2)

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to !Navigate Farm
Facility Name: CASTLE BAY
Facility Type/Classification: Si Facility Grade. Select
Permittee Owner/Officer Name: AQUA NC
Email Address: JAM QAQWMERICA.COM
Permittee Signature:
ORC
Permit # W00018755
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Date: M- + f
Full Name: Dou las Lynn Poe Work Phone:
Email Address: [e-mail]
Certificate Type: SI
Certificate Grade. Select
Certificate #: 1010311
Signature: Effective Date:
'I certify that t agree to my designation as 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 nA NCAC 08G.0204 and failing 10 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:
"! certify that i agree to my designation as the Operator in Responsible Charge for the facility noted l understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC os set fart# in 15A NCAC 08G .0204 and failing to do sa can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full dame:
Certificate Type: Select
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"I certify that l agree to my designation as the Operator in Responsible Charge far the facility noted. l 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-o€fices
or fax using this drop down list: Wilmington-127 Cardinal Dr., Wilmington, NC 28405-2845 l FAX: [phone] l PH: 910-796-7215
Use the 2nd page only if you need to list additional Backups,
Revised 0212024