NC0036269_Operator Designation_20180802

A a. 2. 2018 11:19AM
No. 4983 P. 1
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G.0201
Press TAB to enter information
Permittee Owner/Officer Name: Travis Mark Fowler
Mailing Address: 6400 Breezy Lane
city: Concord
Email Address:
Signature:
Phone: [phone]
State: NC zip: 28025
Facility Name: Rocky River Regional WWTP
County, Cabarrus
Permit# NCO036269
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type
WW
Q
Facility Grade:
IV
0
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name John Walter Ritchie Work Phone [phone], x114
Certificate Type: WW
Email Address: [e-mail]
Certificate Grade: IV
0 Certificate #: 990814
Signature: q��M7Effective Date:
"I certify that/ agree y designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC asset forth in 15A NCAC 086.0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Braden Joshua Cook Work Phone: [phone], x118
Certificate Type: WW
Email Address: DC0CK(0)WSaCC.Org
Certificate Grade: IV 0 Certificate #:1002815
Signature:Effective Date: 2 f 118
"1 certify that I agree to my desrg otion as a Sack -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 ORC as set forth in 15A NCAC 08G.0204 and foiling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mall Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mall or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone! 910-433-3300
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax: [phone]S Fax: [phone] Fax; 336-776-9797
Phone: [phone] Phone: [phone] Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
ReWsed 4@016

A a. 2. 2018 11:19AM
WPCSOCC Operator Designation Form (continued)
Facility Name: Rocky River Regional WWTP Permit #:
No. 4983
NCO036269
Page 2
BACKUP CIRC
Print Full Name: Karen Renee Marie Work Phone: [phone], x118
Certificate Type: WW Certificate Grade: IV 0 Certificate #:1002612
Email address: [e-mail]
Signature: Effective Date:
'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 ORC as set forth in ISA NCAC 086.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certiflcatlon Commission."
BACKUP ORC
Print Full Name: Jesse Lee Wingler Work Phone: [phone], x118
Certificate Type: WW 0 Certificate Grade: IV Certificate #:1004838
Email Address: [e-mail]
Signature:�` Effective Date:
"I certify that 1 agr to my desi nation os a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth In 15A NCAC 086.0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
. BACKUP CIRC
Print Full Name: James Christian Sims Work Phone: [phone], x118
Certificate Type: WW
Email Address: jams
Signature:
Certificate Grade: IV 0 Certificate #:999309
Effective Date: 7- P 6 -/ .9
"I certify that I agree(qmy designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulat ons pertaining to the responsibilities of the ORC as set forth In ISA NCAC 08G.0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
BACKUP CIRC
Print Full Name: Matthew Dwayne Isenhour Work Phone: [phone], x118
Certificate Type: WW
Email Address:
Signature:
Q Certificate Grade: IV 0 Certificate #:1002601
certify that 1 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 ORC as set forth In ISA NCAC 08G.0204 and folling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
RevNsed 4t2016

A a. 2. 2018 11:19AM
WPCSOCC Operator Deslgnatlon Form (continued)
Facility Name: Rocky River Regional WWTP
No. 4983
Permit #: NCO036269
Page/--?
BACKUP ORC
Print Full Name: Joseph Thomas Godwin Jr. Work Phone: [phone], x118
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #:1006400
Email Address: [e-mail]
Signature•
Effective bate:
I certify that/ 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 ORC as set forth in ISA NCAC 08G.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP CIRC
Print Full Name: Nicholas James Merwin work Phone: [phone], x118
Certificate Type: WW
Email Address. nmerWln
Signature:
Certificate Grade: III E Certificate #:1005194
Effective Date: 727-41
I certify that/ 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 ORC as set forth in 15A NCAC 08G.0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP CIRC
Print Full Name: Work Phone:
Certificate Type: Select 0 Certificate Grade: Select 0 Certificate It:
Email Address:
Signature: Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the faclllty noted. I understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth In ISA NCAC 08G.0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP CIRC
Print Full Name: Work Phone:
Certificate Type: _Select 0 Certificate Grade: Select Q Certificate #:
Email Address -
Signature: Effective Date:
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 ORC as set forth in 15A NCAC 08G.0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
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Arg. 2. 2018 11:19AM No.4983 P. 4