NC0068705_Operator Designation_20180628

RECEIV eumw- • --• • •
IUN 2 8 2018
Water Pollution Control System Operator Designation Form
W KSOCC WOROS
NCAC ISA 8G .OZ01. MOORESVI E REG ANAL OFFICE
PermitteeOwnerlOfficerName: t L r
�ctrine.s
Mailing Address:/6317.
1 a� /�— $Z7 8= Phone
a State: ��,Zm: -
City: t i-�S C 0M/I SG✓1 CC
Email address: CLW 0.�"n re h /t -2 l
�,--NCQUfo5
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...............
..... ...i r ua r�r �E{'S W 1rJ �T P Permit #: ,C
Facility Name: ,�—.--
SUBMIT A-SEPpRA CE FORM FOR EACH TYPE SYSTEM!
F Bili
2, Surface Irigation
Biological VVWTP land Application
PhY��UChelnit�il
Collection System ................ . .............
........................................ .
Operator in Responsible Charge (ORC) 11T
Print Full Name:
Certificate Type,
Work Phone N: (7q'( 1 �
Date:
Signature:'
`Y cestifythatI agree to designation as.the :Operatorin Responsible Charge for the facility eeted.ivnderstand and:�yill abidebylheniles
.and regulalionspertaining to themsponsibilirles of the ORC as set forth in 15A NCAC 08G 0204 and Tailing to do so. can insult is Disciplinary
Actions bythe Water Polluhon Control System Operators Certification
.ommisst...........
on-.
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.............. ..
Back Up Operator in Responsible Charge (BU ORC)
Certificate
WorkPbone#: am,
/,
Date: l 2H �! _ .
Signature:
"I certify thal l Y'des, stiou as a Bibilmno es of the$lj o C as setima ttorth m 15x1 NCAC e for the 08G 0'0 and tail g to do Olean result to e
rules aadregulatio atntngto the respo eretors 4eriificmion Commission" .........
Actions by the Water Pollution Control System Op .................
•••••••
Disct......Y -
Mail, fax'oremai! the WPC80CC, 1618 bled ServrceCenter, Raleigh, NC 27699-1618 Fax:919:807. -92
..
origindto• EWaB•ee °dcnr env \` Raleigh
0 Mooresville $
Mall orfax a copy to theAsheville
.appropriate-Aegional office.2090 Unna 2 77)
Swannanoa 2R77R
Fax::[phone]
phone: [phone]
Washington
943 Washington Sq.Mall
Washington 27689
Fax:252.946:9215.
Phone: [phone]
Falettevt e
225 Green St
Suite 714
Faz:91.0.486.wo! L
Pho
Phone: [phone] -
Wilmington 581
127 Cardinal Dr
SVilmington 28405-2845 ME
Fax: [phone] Fax
Phone: [phone] Ph(
3800 Barrett Dr.
Raleigh., 276D9
Fax:919S71s471S
Phone:[phone]
Revised 02'2013.