WQ0018755_ORC Designation Form_20241115

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: CASTI_EBAY WWTF
Facility Type/Classification: WW Facility Grade: Ii
Permittee Owner/Officer Dame: AQUA NC
Email Address: [e-mail]
Permit # WQ0018755
SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Signature: Date:
ORC
Full Name: ©avid Kane Work Phone:
Email Address: [e-mail]
Certificate Type: WW Certificate Grade: 11 Certificate #: 1014570
Signature: L_- __� \ I
Effective Date: to/o - 1
"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 os set forth in 15A NCAC 08G.0204 and failing to do so can result in Disciplinary Actions by the INKSOCC"
Backup ORC
Full Name: Jon Fox Work Phone:
Certificate Type: WW Certificate Grade: I Certificate #: 1012799
Signature: 4 ox-- Effective Date: I2_ `( — C.-
certify that 1 agree to my designation alle 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 0BG .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:
I certify that! 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 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: Wilmington-127 Cardinal Dr., Wilmington, NC 28405-2845 1 FAX: [phone] PH: 910-796-7215
Use the 2nd page only if you need to list addit€onaI Backups.
Revised 0212024