NC0074268_ORC_Graham_20180226

Feb, 26. 2018 1:50FM
DS '
No 2656 P 2/3
WATER POLLUTION CONTROL ,SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Permittee Ownerf Officer Name:
NCAC 15A 8G.0201
Press TAB to enter Information
David Shellenbarger
Mailing Address: P.O. BOX 1748 Phone: [phone]
City: Gastonia n state: NC zip: 28053
Email Address: [e-mail]
Signature:
Date: 9- /a,(,/ ' S'
Facility Name: Crowders Creek VWUTP Permit it NCO074268
County: Gaston :���- ---- -
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: VVW
Facility Grade: IV
O,PERAT.OR IN.RE PQ NSIR.LE',C�IA.RGE (OR
C)
Print Full Name: Michael C. Graham Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 28534
Email Address: [e-mail]
Signature:
Effective Date: /J� lgc) i
"I certify that/ agree to my designation as the Operator in Responsible Charge for the facility noted. 1 understand anJ will abide by the
rules and regulations pertaining to the responsibilities of the DRC as set forth in 15A NCAC 08G.0204 and failing to do so can result in
Disciplinary Ac#ions by the Water Pollution Control5ystem Operators Certification Commission."
B�CICt.PR
Print Full Name: Devin M- Graves Work Phone: [phone]
Certificate Type: VWV
Certificate Grade: IV Certificate #: 999374
Email Address: kevingtworiversutilities.com
Signature: �. Effective Date: 0?_/ZC2or '
"I certify that 1 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 1VCAC 086.0204 and foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification, Commission."
Mall fax or email WPCSOCC 1618 Mail Service Center, Fax: [phone]E
ca rid enr;gdv
ORIGINAL to: Raleigh, NC 276991618
Mail or Fax Asheville
a COPY to: 2090 U5 Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: 2S2-946-6481
Fayetteville
225 Green St:, Suite 714
Fayetteville, NC 28301-5043
Fax; 910-486-0707
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax., 704-663-6040
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax:[phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 4/2078

Feb, 26. 2018 1:50FM No, 2656 F. 3/3
WKSOCC Operator Designation Form (continued)
Facility Name: Crowders Creek WVVTP
Permit #: NCO074268
Print Full Name: rlisha Baker Jr. Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: [e-mail]
Signature:
Certificate #: 995899
Effective Date: p-;6—(8
Page 2
'Icertify 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
DisciplinoryActions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORS .
Print Full Name: Douglas E. Barker Work Phone: [phone]
Certificate Type: VM Certificate Grade: IV Certificate #. 21867
Email Address: dougb@a tworiversutilties .corn
Signature: Effective Date:
"1 certify that/ agree t my designation as a Back-up Operator in Responsible Charge for the facility noted I and rstand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G.0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
„ BACKUR CIRC
Prim Full Name: Earl C. Beach Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV Certificate #t: 10661
Email Address: [e-mail]
Signature: Effective Date: -, Cp/ or
"I certify that 1 agree to my designation as a Sack -up 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Hubert H. Hampton Work Phone: [phone]
Certificate Type: WW
Email Address: hughh
Signature:
Certificate Grade: IV
com
Certificate #: 26513
Effective Date:
"I certify that I agree to my designation as a Back-up 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."
Revised 412016