NC0025348_Water Pollution Control System Operator Designation Form_20190417

Water Pollution Control System Operator Designation Form 4pR
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
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Mailing Address: ®O 1& 4- /I Z ° / .527 /u c I n;.. 55 Ll-) [� Q? ce
City: Pew B e — State: Pe- Zip: '2- s6 33 - Phone #: 2T z - 63 S - ? > i 7
Email address:
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>igna re �/ Date: -
Facility Name: C Netx 'se li✓wT)� Permit #: PCC�1 0 2 5 3 LI ?
County: (ra ve- v\
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
................................................................................................................................................
Operator in Responsible Charge (ORC)
Print Full Name: y A S
Email:
Certificate Type / Grade / Number: tV wgy
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Work Phone #:
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Signature: ��i �-. Date: L-/ 1 6,
"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: Ar t No u
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Email:
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Certificate Tvne /Grade /Number: WW �/
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Work Phone #:
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Signature: i Date: © 0
"I certify that I agree to my des' ation as a Back-up Operator in Responsible Charge for the facility noted. I underst d 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."
...................................................................................................................................................
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
orijzinal to: E►nail: certadmim"a:ncdenr.j!o,
Mail or fax a copy to the
appropriate Regional Office.
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015

WPCSOCC Operator Designation Form, cont.
Facility Name: C�+)z r (Ur wt-11—)0 Permit #: yc D 07- 3 Y?
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: �U_c> _ c_o ff Email: ,S(- 0 /79 s�2' 14 P w b e­\ h c - go V
Certificate Type / Grade / Number: L-'w L4 9 � 3 7 3 a- Work Phone #: 2 17 , 2-
Signature: Date:
"I certify that I gr 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." - -
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
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 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."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Email:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
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 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."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
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 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."
Revised 05-2015