NC0087858_Other_20181228

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Equipment & Supply, Inc.
Mailing Address: 4507 Highway 74 West Phone: [phone]
City: Monroe State: INC Zip: 28110
Email Address: tim@equipsy,com _
Signature:
Facility Name: Equipment & Supply, Inc.
County: Union
Date:
Permit # NCO087858
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: _TPC
Facility Grade: I
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DEC 2 8 2018
WOROS
MOORESVILLE REGIONAL OFFIC
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Richard Laurance Harmon Work Phone: [phone]
Certificate Type: PC Certificate Grade: I Certificate M 988627
Email Address:
Signature: �yf r.,.. Effective Date: //Z/
% certify that I agree to my designotton 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 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: Kellle Hedrick Work Phone: [phone]
Certificate Type: PC Certificate Grade: II Certificate #:28628
Email Address:
PSCCharlotte.com
Signature: L Effective Dat : 11/11P,fis
"I certify that I agree to my esignatlon 6s a ck-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 asset forth in SSA NCAC 08G .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]D43
Phone:[phone]
Washington
943 Washington Sq, Mall
Washington, NC 27889
Fax: [phone]
Phone:[phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301.5043
Fax:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone:[phone]
Mooresville
Raleigh
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Mooresville, NC 28115
Raleigh, NC 27609
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone:[phone] Rewsed412016