NC0032867_Other Agency Documents_20190226

Water Pollution Control System Operator Designation Form
'"TCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer frame: Lag e q K
Mailing Address: 100 ®i X o h s C� 001 Rd
City: KrhgS Mo"*\1 zi i, State: MC Zip: 2 �08 -
Email
...................../..,.......... ...,...................................... ...
Phone #: '717 721? - 024-9
Date: r)— a I` r
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Facility Name: Val V�. 9 5 M0 tA.o N+CX`W t Tr cLy e ca ct Permit #: N C O0328 6 7
County: de V e 1 CLrr%
...................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/crass (CHECK ONLY ONE):Biological . Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: s.tnie ` J ®®4 c riy Email: " 111& v--t V S P 6 �RK'z a 1 . C.0 nn
Certificate Type / 'ade / Number- Ww 4 el S 8 5 7 3 Work Phone #: 70 t,f 1+7 7 - S S 1 4-
Signature: ' L1� Date:2
"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 vPollution Control System Operators Certification CommiissionveseOev v.eee' e v e
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: W i 11 i a rh A. Email, W rActhpyp' e5 lyc� l • Car
Certificate Type / Grade / Number: W 1V 1 1007 (8 2 Work Phone #: 7® 4 Po 1 4 6 7 29
Signature: U/ Atow ✓C, ldw!! ./. Date: -2 `7 /_ IV
"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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
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Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
orininal to: �, mail; xertadminfaDnedenr.¢ov
Mail orfax a copy to the
Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office:
2090 US Hwy 70
225 Green St
610E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
.IV lililt tiNl-:h SNP
Phone: [phone]
Fax: [phone]
Fax: [phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
MAR
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2945
Winston-Salem 27105
' - ;VII i r" 1
Vax: 252.946.9215
Fax: [phone]
Fax: [phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015