NC0068888_Operator Designation_20180423

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Select 4l=aAzd
NCAC 15A 8G .0201
Raleigh
a COPY to: 2090 US Hwy 70
225 Green St., Suite 714
Press TAB to enter information
3800 Barrett Dr.
Swannanoa, NC 28778
Permittee Owner/Officer Name:
Do
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Fax: [phone]
Mailing Address:
?J0 k, 901j4,00 S;
Fax: [phone]
Phone: 70 /- 9dd -3i %C
City:
P 5 State:
/V C-1
Zip:
Email Address:
7yt64r-awDe6+ Okillr6,10. neo
Signature :
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Date:
Facility Name: `6ijN UR Wh(-Lr1j
Permit # ^[Ca
Cf -&3388
County: G'4-bry/f
RECEIVEDINCDENRIDWR
ITR 2 3 ?018
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
—� WOROS
MOORESVILLE REGIONAL OFFICE
Facility Type:
Select 4l=aAzd
Facility Grade: ISelect
Raleigh
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Work Phone: ;76)
Certificate Type: Select Certificate Grade: Select ;7V- Certificate #: �y
Email Address:
Signature: aizt Effective Date:
"9 certify that 1 agre to my designation as t Operoto n 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."
BACKUP ORC
Print Full Name: "g2nDwvf Ly{ yyy, autW 7t%i Work Phone: JUS/-,T/i/.(, s$�
Certificate Type: Select Certificate Grade: Select Certificate#:
Email Address: hfj�Ill�r(�upg)J!> l�E'-r
Signature: � i J _ �' Effective Date: 4-/-d 7 • W /9
"7 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. /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
Fayetteville
Mooresville
Raleigh
a COPY to: 2090 US Hwy 70
225 Green St., Suite 714
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Swannanoa, NC 28778
Fayetteville, NC 28301-5043
Mooresville, NC 28115
Raleigh, NC 27609
Fax: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Phone: [phone]
Phone: [phone]
Phone: [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]
Revised 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Select rM /
NCAC 15A 813 .0201
Raleigh
a COPY to: 2090 US Hwy 70
225 Green St., Suite 714
TAB to enter information
3800 Barrett Dr.
Swannanoa, NC 28778
Permittee Owner/Officer Name:
nPress
c-� b'Y f%jj
c�pr4 fj p
Fax: [phone]
Mailing Address:
?fo ^(, H�II4Nn �'T.
Fax: [phone]
Phone: 1)2V -3i /C
City:
�� S State:
/V 6_1
Zip:
Email Address:
7N 5 /rau�t �il ck/i/I.sne, �e
Signature:
7U/aLt� ,C��cc,_QS�
Date: W
Facility Name:'��JN UR I✓A"5
5;t, 0Age9_ Pta l4'
Permit # /C
r`�a'-3gs
County: G.4- ry/t/
RECEIVED/NCDENRIDWR
APR z s ?018
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
11
WOROS
MOORESVILLE REGIONAL OFFICE
Facility Type:
Select rM /
Facility Grade: ISelect
Raleigh
I OPERATOR IN RESPONSIBLE CHARGE (ORCI I
Print Full Name:
Certificate Type:
Email Address:
Signature:
Certificate Grade: Select;JLT
Work Phone: ZW I��—a�;?i
Certificate #:
"I certify that I agreirto my designation as tW OperatoMn 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 Fuli Name: �jRd js�( [,y y () .;Fye] Work Phone:4_ s$b�
Certificate Type: Select Certificate Grade: Select Certificate #: Cf,7 g3`);z
Email Address:
Signature: Effective Date: Y -d-7• W 15
"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 Con trolSystem 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
Fayetteville
Mooresville
Raleigh
a COPY to: 2090 US Hwy 70
225 Green St., Suite 714
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Swannanoa, NC 28778
Fayetteville, NC 28301-5043
Mooresville, NC 28115
Raleigh, NC 27609
Fax: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Phone: [phone]
Phone: [phone]
Phone: [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]
Revised 412016