NC0062278_Operator Designation_20180628

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Water Pollution Control System Operator Designation Form SUN 2 8 7lllb
NNIPCSOCC
NCAC ISA 8G.0201 WOROS
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EGIONALOFFICE
permittee OxlmerlO►BcerName: - _ '� --- �— /
Meiling Address:
^^' i Phone 9: t s) LO5a:�
City: State: Lr�--LP �.`.'�`i� ----
Email �,
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Signature:Signature:— — —
Date:
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Permit q:
Fadl[ty Name:
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Farn'w� z TWr/C'tAde:
Sur4at= IrriKalien
Biological WWTP --- Lu,dApplication
Physical/Chemical __
Collection System ...................
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Operator in Responsible Chargle�(ORC)
Print Full Name:-
CerdBcate Type / Grade ! Number: -WW 10QScf 0 S__ Work Phone g: 1'7//()11�) y � Q��165
Date: ` t– �—�----
Signature:
that 1 to my designation as the Operator in Responsible Charge for the fariliry notal. I understwld and vnll result by the ipli
to the imp of ase ORC u: set Gent, in I SA NCAC 08G 0201 amp fsiting to do so tall result in Disciplinmy
and regulations pertaining ......
Actions by the ...................................
Water Po...... Control System Operator C......... Co.... ...
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Back -Up Operator in Responsible ChargeMIS�OR�1 � n
Prim Full Name: ' IL II� - - — -. 5O/ _ --1� o
{" _l_IW �_. Work Phone �:
Certificate Type /Grade !Number. _
Signature: - -------
.q urelty thu 1
we to y designs +cm as s yih lilies of thct{y) iP.(' i°ass hlforth �ISA N(:,k('
t for the 9gli A2U and ailing to do soiwn tresuh inde by
nilas and regulations wining to 0,e rcs7wn .. ,.
Diseiplinary Anions by the WMer Pollution Control System Opt...... Cell........ Co......... .. ...
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AfaU.jaxor.. the WPCSOCC:, 1618pdoil service Center. Raleigh, - 7G 8 Fax:[phone]
original to: Pmall•rtnp�:�nrdertryrn_v_ Raleigh
Far -lit IHit 3luortsvii
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Matf orfate a copy ra the Ashe•0tr a ,ran St 6IU E Ce1800 BonUt Dr
Ce, 2090 tIS I Isty 7U ;wile 301leigh 27609
appropr Swanntasoa 28778 `-a+11, 71'1 aa: 919371.4718
x:828.279.!043 Rr,euev01u283p1-50 3 klonrcsaihane:919.7914200
Phone: [phone] Fax: 910.486.070'7
Pax: 104
Phony: 910.133.3300 I'hunr: 7
\F ilmingWn Washington
A 943 Wash ngtou Sq Mall 127 Cardinal Dr 8
05 Coe, Washington27889 \'ilmu, 0.32.1019 45 1\'!;336. glen 27107
Fax: [phone] Fa•:910.350:2111µ 1•ex:,,:1.771'4631
l.! Phone. [phone]:181 Movie. 110.796.'720'Cbnae: }3G.Tt13g00 Ravisod 02-2013