NC0036196_Operator Responsible Charge_20180521 (2)

Water Pollution Control System Operator Designation Form
WPCSOCC RECEIVEDINCDENRIDWR
NCAC 15A 8G.0201
Permittee Owner/Officer Name: sl qr PAC � IAIEN T-2 MAY 21 2018
g �' t . j( 550 wsm"I
OROS
Mallin Address: e� J Mnnavc:ru i c o
City: P1 St//ate: Iv C Zip: Z o5 Phone #: 10- 0 .- L%.?,Y 6
Email address: t'-!t•T 2, - L -w vt n C •
Signature: Date: S /) S l 1 0
................................r.....t.........................................
Facility Name: Ct+�®k IVew4h Permit#• NC W""�6116
County: (;t`k'TALV16A
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
................................................................................................................................................
Operator in Responsible Charge (ORC) //
Print Full Name: �' It Mp 5 l ll! ` •�y 9 f 5 Email: 24JU t�'S' (d `'I&. h",n e., `Y V
Certificate Type Grade / Number: )1, �r ' t f f I } l Work Phone #: �� % S - Y � 7 C
Signature: Gy/V:x!•� ' Date:
"I certify that I agree Wray designation as the Opdtrator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations perta' g 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..
.. ..
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: �Ge "o f Email: €) h e a n
Certificate Type / Grad / Number: 'J/&441 `)y M? Work Phone #:
Signature: � � Date:
"I certify that I agree to VAesignation as ap Operator in Responsible Charge for the facility noted. I understand and will abide by the
Pules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC HG .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
..................................................................................................................................................
Mail, fax or email the WPCSOC(', 1618 Mail Service Center, Raleigh, Ni; 27699-1618 Fax: [phone]
original to: Email: certadnaiaLa1ncilov
Mall or fax a g= to the AsbevOle
appropriate Regional Officer 2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington. Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
1VOtningtnn
127 Cardinal Dr
Wilmington 28405.2845
Fax: [phone]
Phone: [phone]
1lluores011e
610 E Center Ave
Suite 301
Nicoresviile 28115
Fat: 704.663.6040
Fhone: 104.663.1699
Winston-Salem
450 W. Hanes Mali Rd
Winston-Salem 27105
Fax: [phone]
Phore: 336.776.9800
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
OFFICE
Revised 05-2015

WPCSOCC Operator Designation Form, cont.
Facility Name: 6A v f' Alet✓ -& O'VIV ((Will' "7F Permit #: AIC 0 0U) 9 6
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: _/ wij L /Tpf F 41to Email: e' • ti6 1d
Certificate Type/ Grade/ Number: &tgc d%&4r'V IOL 365 t Work Phone #: Z�' — � f«'s�%3 13
Signature: Date: 5-
1
"I certify that [ agree to designation s a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations ertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
"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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
'Y 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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree io my designation as a Back-up Operator 4<, P espousible Charge, fur the facility noted. i understand and will abide by the
Hiles anu. regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can residi in
Disciolinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 05-2015