NC0023353_ORC Designation Form_20241118

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
Facility Name:
TOWN OF WHITE LAKE
NCAC 15A 8G .0201
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Permit # NCO023353
Facility Type/Classification: WW Facility Grade: I SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: H- Goldston Womble, Jr.
Email Address: [e-mail]
Permittee Signature: Date:
ORC
Full Name: Kevin Taylor
Work Phone: [phone]
Email Address: [e-mail] '
Certificate Type: WW
Certificate Grade: III Certificate #: 1001446
Signature:
Effective Date: //-I-
certify that I agree to my d signation as the Opera
esponsible Charge for the facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A
C 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: William Stafford
Work Phone: [phone]
Certificate Type: WW
Certificate Grade: ll Certificate #: 15904
Signature:
Effective Date:
"I certify that i agree to my designation as the Opera
rn Responsible Charge for the facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 154
CAC 08G .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 1 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: Choose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 02/2024