NC0088722_Other Correspondence_20190422

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FAIR (,,IWI ,�SOCC)
NCAC 15A 8G .0201 �> F
'Af l _21
Press TAB to enter information
Permittee Owner/Officer Name: Donald V. Chamblee WO';OS
Mailing Address: 115 West Main Street Phone: [phone]
City: Lincolnton State: NC Zip: 28092
Email Address: [e-mail]
Signature: :��j.V° I Date: `,Z,
Facility Name: Killian Creek WWTP
County: Lincoln
Permit # NC 0088722
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: James T. Simmons Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 1001451
Email Address: [e-mail]
Signature: l �' ,.e Effective Date:
"/ certify that / agree t m designation as the Operator in Responsible Charge for the facility noted. / understand and will abide by the
rules and regulations per aining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions b e Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Brian A. Koon Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #:1005670
Email Address: [e-mail]
Signature:7F72A��Effective Date: 14llZ19
"l certify that/ 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 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] drn€ricdrir goy-
L to: Raleigh, NC 27699-1618
Mail or Fax
a COPY to:
Asheville
2090US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
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
610 E. Center Ave., Suite:301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]d
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued)
Facility Name: Killian Creek WVVrP
Permit M NC 0088722
BACKUP ORC
Print Full Name: Rusty L. Carpenter Work Phone: [phone]
Certificate Type: WW
Certificate Grade: III
Email Address: ricarpenter@lincolncounty
Signature:
Certificate M 1005909
Effective Date: I ` t �- ) q
Page 2
"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 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: Robert H. Hinson Work Phone: [phone]
Certificate Type: WW
Email Address: rhinson@linco
Certificate Grade: III
Certificate #:1007632
Signature: Effective Date:
"I certify that I agree famy 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
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"/ 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
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"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
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 412016