DEQ-CFW_00060872

a' f nO�T DuPont Fluoroproducts
(� �+ I ® DENR-FRCS Fayetteville,
NC e, NC 28 0 West
Fayetteville, NC 28306-7332
AUG 18 2010
DWO
WPCSOCC
1618 Mail Service Center
Raleigh, NC 27699-1618
August 17, 2010
Subject: Revised Designation Form for the Operator in Responsible Charge
DuPont Company — Fayetteville Works
NPDES Permit No. NC0003573
Dear Sir or Madam:
Enclosed is the new Water Pollution Control System Operator Designation Form for the
DuPont Company — Fayetteville Works facility. The change on this form is due to the
change of the site's ORC from a Grade 3 to a Grade 4 operator.
If you should have any questions, please feel free to call me at [phone].
Michael E. Johnson
Environmental Manager
Enclosure
cc: Ms. Belinda Henson, NCDENR DWQ, FRO
E.I. du Pont de Nemours and Company
DEQ-CFW 00060872

Water Pollution Control System Designation Form
WPCSOCC
NCAC 15A:08G .0201
Permittee Owner/Officer Name: DuPont Company / Karen B. Wrilimey
Mailing Address: 22828 NC Hi hway 87 W
City: Fayetteville State:: NC Zip: 28306-7332 Phone #: [phone]
Signature: � bo Date: l /%
...............................................................................
Facility Name: DuPont Company— Fgyetteville Works Permit #: NC0003573
County: Bladen
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM!
Facility Type and Grade:
Type Grade Type Grade
Biological WWTP X 3 Spray Irrigation N/A
Physical/Chemical Land Application N/A
Collection System
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Operator in Responsible Charge (ORC)
Print Full Name: Jamie Rqy Lewis -
Certificate Type / Grade / Number: WW / 4 / 994529 Work Phone #: [phone]
Signature:
"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 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."
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Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Arnold Ray Beard
Certificate Type / Grade / Number: WW / 2 / 28791 Work Phone #: [phone]
Signature:
"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 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."
■.......rr.r.rr....r...■rrrrrrrr..■.■■........r.r...rr............r..■■....rr.■
Mail or Fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(See next page for designation of additional back-up operators. Designation of more than one back-up operator is optional.)
Revised 8-2007
DEQ-CFW 00060873

Additional Back-up ORC designations
Facility Name: DuPont — Fayetteville Works Permit M NC0003573
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: E. Russell Rotan
Certificate Type / Grade / Number: WW / 3 / 21886 Work Phone #: [phone]
Signature:
"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 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 in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone M
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abid
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."
■.■■■.r.■■■■.■■■■■.r■■■■■.rr■■■■ a r.r.■■■■....■■■r.....r..............r■r■r■■.■
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
"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 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 in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
"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 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."
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Revised 8-2007
DEQ-CFW 00060874