NC0081621_Operator Designation_20180802

A a. 2. 2018 11:16AM
No. 4981 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: mfowler wsacc.org
Signature:
Facility Name; Muddy Creek WWTP
County: Cabarrus
Phone: [phone]
State: NC zip: 28025
Date: -1 /31 1 tej
Permit it NCO081621
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
WW Ej
Facility Grade:
II Q
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Kimberly D. Holt WorkPhone- 980-521-8611
Certificate Type: WW 0 Certificate Grade: IV Q Certificate N: 993802
Email Address: [e-mail]
Signature: Effective Date:
"I certify that I agree to my 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- John Walter Ritchie Work Phone: [phone], x114
Certificate Type: WW 0 Certificate Grade. IV Q Certificate (1:990814
Emall Address• )[e-mail]
Signature: �7-��EffectiveDate:
////
"I certify that I agree 4 -ml y 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 Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail 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: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone; 704-663-1699
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] Fax: [phone] Fax: [phone]
Phone: [phone] Phone:[phone] Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax; 919-571-4718
Phone: [phone]
Ra"ed 412016

A a. 2. 2018 11:16AM
WPCSOCC Operator Deslgnatlon Form (continued)
Facility Name: Muddy Creek WWTP
No. 4981
Permit M N00081621
Page 2
BACKUP ORC
Print Full Name: James Christian Sims Work Phone: [phone], x118
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate 31:999309
Email Address:
Signature:
Effective Date: -1-2(,-1
"1 certify that 1 agree tgAFy designation as 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 foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Matthew Dwayne Isenhour Work Phone -704-788-4164, x118
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #:1002601
Email Address:
Signature:
Effective Date: -21-311,1h
'1 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 failing to do so can result in
DlsclpllnaryActions by the Water Pollution Control System Operators Certlflcation Commission.'
BACKUP ORC
Print Full Name: Karen Renee Marie Work Phone: [phone], x118
Certificate Type- WW E] Certificate Grade! IV 0 Certificate #:1002612
Email Address: [e-mail] p (y
Signature. ILS Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. /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 ORC
Print Full Name: Christopher Scott Yost Work Phone: [phone], x118
Certificate Type: WW QCertificate Grade. 11 0 Certificate#.1002797
Emall Address: cyost@w.{�ssacc.Org
Signature: -[7 '/ . Effective Date: 7- 2-
"I
"I certify that I agree to my designation as a Back-utfoperator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC os 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.'
Revised 412016

A a. 2. 2018 11:16AM
WPCSOCC Operator Designation Form (continued)
No. 4981 P. 3
Facility Name; Muddy Creek WWTP Permit M NCO081621
Page /2
BACKUP ORC
Print Full Name: Jesse Lee Wingler Work Phone: [phone], X118
Certificate Type: WW
0 Certificate Grade: IV 0 Certificate #1:1004838
Emall Address! [e-mail]
Signature: L4, lal/r�, Effective Date: %acs /Ff
"I certify that I agre�my desigEiation as 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 08G.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: Joseph Tho mos God W i 6 J -f, Work Phone: [phone], x118
Certificate Type: WW
0 Certificate Grade: IV Q Certificate fl:'/OQ (a 4J
Email Address: [e-mail]
Signature:• �. Effective Date: 7- 2%1
"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 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: Nicholas James Merwin work Phone! 704-788-4164, x118
Certificate Type: WW Q Certificate Grade: III Q Certificate #:1005194
Emall Address: nmerwln@Wsacc,org
Signature: 41�- Effective Date: ';7- 2 7-
"i
"i certify that I agree to my designation as 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 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: [e-mail]
Signature:
0 Certificate Grade: 1V 0 Certificate #:1002815
Effective Date: -4,b-418
"I certify that I agree to my deslgAlon 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 086.0204 and foiling to do so can result in
Disciplinary Actions by the Water Pollution Control system Operators Certification Commission."
Revised 412016