WQCS00093_ORC Designation Form_20241115 (2)

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Town of North Wilkesboro
Email Addre s: [e-mail]
Permittee Signature:
Facility Name:
North Wilkesboro Collection System
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: CS -III
Date: /— �2¢
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Permit #
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Danny Allen Porter Work Phone: [phone]
Certificate Type: CS
Certificate Grade: IV
Email address: [e-mail]
Signature
Certificate #: 1013986
Effective Date: 11_ 12-Z4
"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 086'.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: Zachary Tyler Stines Work Phone: [phone]
Certificate Type: CS Certificate Grade: II
Email Address: [e-mail]
Signature
Certificate #: 1008455
Effective Date: 11-1Z-1-¢
"I certify that I agree to my designation 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, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115
Fax:[phone] Fax:[phone] Fax:[phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax:[phone]
Phone: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 1112020