NC0022497_Operator Designation_20180628

Water Pollution Control System Operator Designation Form,,, `,, 8 1117
WPCSOCC
NCAC 15A 8G.0201 r WORDS
Permittee Owner/Officer Name:
Mailin�igAddress: UUtT I r ' v —
City: ►Jt Y�\I P --_II r State: -! C Zip: �%O�J� Phone #: 8S 4-55` QGa'9
a
Email address: — r nd '
Date:
Signature:
...............................................................
................
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fMl �UA GWP Iy r\'�' Permit #: NN
Facility Name: t —
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tvoe/Grade-
Biological WWTP - _ Surface Irrigation
Physical/Chemical Land Application
Collection System
..............::...................................................................
Operator in Responsible Charge (ORC) 1 1
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( 1
Signature: (jt. Tq,4w Date: 4
`Y certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the niles
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." ......................................................
..................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: `K--��I—Pn�
Certificate Type{ Grade / Number:
.. - 01 111; R�l�lriiv' �`fl��
Date: 4— L—)
`2 certify that I a to my signation as Back-up Operator in Responsible Charge for the facility noted. i understand and will abide o so can It the
h in 15A NCAC 08G.0205
rul
and
the
iesof the BU
on
Disciplm r. gala' ons by t�lre Water PoIIPCSOCCt•ution 11618mMai �C wicetors tC� �[er, Ra
e gh,�NC 27699�d 81mFaxg to a919.8076492m.
Marl, fax or email the W
original to: Email: certadminkncdenr.sov - '
Asheville Fayetteville ooresville Raleigh
Mail orfax a copy to the Asheville
US Hwy 70 225 Green St 610 L Center Ave 3800 Barrett Or
appropriate $egional Office: Suite 301 Raleigh 27609
Swamanoa 28778 Suite 714
Fax: [phone] Fayetteville 28301-5043 Mooresville 28115 Fax: e: 9 9.791.18
Phone: [phone] Fax:
ax 910 0.6.0 3300 Fax:Pho704.663. 34099 Phooe:919.791.4200
Pho
Washington
943 Washington Sri Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Or
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Revised 02-2013