NC0020061_ORC Designation Form_20241104

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Town of Spring Hope/Andrew Delonno
Mailing Address: PO Box 87; 118 E Railroad St
City: Spring Hope
Email Address: [e-mail]
Phone: [phone]
State: NC Zip: 27882
Date: -4
Signature: �-
Facility Name: Town of Spring Hope
County:
Nash
Permit # A] C.,Oba-0b�o1
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Matthew D Pearce Work Phone: [phone]
Certificate Type: WW
Certificate Grade:
Email Address: [e-mail]
Certificate #: 1015461
Signature: "yn- Lou, Effective Date: I j - t - L�
"I cert* that 1 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: I/R yo„ G geed c x Work Phone:,,S. L) % S - S-/MCP
Certificate Type: Select t, Ly Certificate Grade: Select / Certificate #:
Email Address:
Signature:
Effective Date: I i - � -
"I certify that/ agree to my design 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Rovised ,J/201 G