NC0064599_Operator Designation_20180628

Water Pollution Control System Operator Designation FOK99EIVEDINCDENRDWR
WPCSOCC
NCAC 15A 8G.0201 JUN 2 8. 2018
Permittee Owner/Officer Name: LLL LG I VUI I 1 t1 I ) 1 t LU I GI LLAT V I I la ICS I esu I l%hm
I I f /� / Mp�R SYI ERE N OFFICE
Mailing Address: ��i)4� Cf/ci�l /iCC/-5`R�1f�iprlJU4/ d�
City: �l �I fl -r(16 5 (' State:Xe Zip: ZV 5 a Phone #: (64) z 7�r— 7—%17
Email address: L 6( N d t h <7 Q f(vl t' R C C -7m R r Ct C-001
Signature: Date: I 2-6
.................................,..........................,............................................................................
n1
Facility Name:
G �e�rnna n Wi7UT
W G Permit #: N ( I
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP Z_ Surface Irrigation
Physical/Chemical Land Application
Collection System
........................................................................................................................................... .
Operator in Responsible Charge (ORC)
Print Full Name: C�rT�rm
Certificate Type / Grade / Number: : Work Phone #: % )
Signature: Date:
"I certify that I agree to my designation as the Operator hr 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
-iinn Responsible Chargtee (BU ORC)
Print Full Name: J �• I Yom._11 _ `_
Certificate Type / e / Numb r: ���� loQ _ Work Phone #: / 141 15010 4a5 5
Signature:Date:
"I certify that I agr to designaL as a Back -u Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulatio fining 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."
................................................................................................................................................
Mail, fax or email the W PCSOCC, 1618 hail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadmin(iDncdenneov )
Mail orfax a copy to the Asheville
Fayetteville-
Sooresv1"0
410E
Raleigh
appropriate legion! Office: 2090 US Hwy 70
225 Green St
Center Ave
3800 Barrett Dr
Swannnoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Phone:[phone]
Phone: [phone]
Phone: [phone]
Washington -
\N ibuington
Winstou-- em
943 Washington Sq Malmo—
127, Cardinal Or
5 aughtovvn St
Washington 27889
Wilmington 28405-2845
Winston-Salem 27107
Fax: [phone]
Fax: [phone]
Fax: [phone]
Phone: [phone]
Phone. [phone]
Phone: [phone]
Revised 02-2013