NC0037371_Other Agency Documents_20190429

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC) ;
NCAC 15A 8G .0201
Press TAB to enter information
Mz {3 ., �,xtJ,
Permittee Owner/Officer Name: Iredell-Statesville Schools/Matt Cartner
Mailing Address: 156 Raider Road Phone: [phone]
City: Olin State: NC Zip: 28660
Email Address: [e-mail]
Signature: .. Date:f
Facility Name North Iredell High School WWTP
Permit # NCO037371
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: Dennis Murdock Work Phone: [phone]
Certificate Type: WW Certificate Grade: III �v Certificate #: 71
Email Address: [e-mail]
Signature: Y �-V rlel�z C l Effective Date:
"l certify that/ agree to my designation as the 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."
BACKUP ORC
Print Full Name: Robert White Work Phone:[phone]
Certificate Type: WW Certificate Grade: 11 Certificate #: 991976
Email Address: [e-mail]
Signature: Effective Date: G f
'7 certify that/ agree o my designation as a Back-up Operator in Responsible Charge for the facility noted. / 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax:[phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone;704-663-1699
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr, 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: North Iredeil High School WWTP Permit #: NCO037371
BACKUP ORC
Print Full Name: Todd Robinson Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 989809
Email Address: [e-mail]
Signature: llh.r z �v` --' Effective Date:C'
/ _l
"1 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted l understand and wilt 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: Marc Nault _
Certificate Type: WW Certificate Grade: II
Work Phone: [phone]
Certificate tt: 9656
Signature: � - �f Effective Date: < 9
"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 Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate R:
Email Address:
Signature Effective Date:
"1 certify that 1 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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC J
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate 4:
Email Address:
Signature: Effective Date
"I certify that/ 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 4/2016

1 Vc`=€Y t.:`.
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: Origin Food Group/George Buff
Mailing Address: 306 Stamey Farm Road
City: Statesville
Email Address:
Signature:
Facility Name: Origin Food Group WWTP
County: Iredell
Phone: [phone]
State: NC Zip: 28687
Permit # NCO077615
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: it
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Dennis Murdock Work Phone: [phone]
ra
Email Address: [e-mail]
Signature: � �� Effective Date: -
"I certify that l 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 ControlSystem Operators Certification Commission."
BACKUP ORC
Print Full Name: Robert White Work Phone: [phone]
Certificate Type: _WW _
Email Address: cwhite@envirolinkinc-
Certificate Grade: II
Certificate #: 991976
Signature: -- � — Effective Date: `_1—19 —/ 7
"I certify that 1 agree to my designation as a Bock -up Operator in Responsible Charge for the facility noted. l 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email:
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq, Mail
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]
Winston-Salem
45 W. Hanes Mail 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) Page 2
Facility Name: Origin Food Group WWTP Permit#• NCO077615
BACKUP ORC
Print Full Name: Todd Robinson Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate tt: 989809
Email Address: [e-mail]
r l
Signature: ����� , Effective Date:
"1 certify that/ agree to my designation as a Sack -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 os 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: Marc Nault Work Prone: 336-528-583$
Certificate Type: WW
Certificate Grade: II
Certificate #: 9656
Signature: � � ( �fac. Effective Date: -/` 9- / 9'
'Icertify that 1 agree to my designation as a Sack• p Operator in Responsible Charge for the facility noted. / 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
Email Address:
Signature:
Certificate Grade: Select Certificate M
Effective Date:
"1 certify that 1 agree to my designation as a Sack -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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"1 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 asset 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

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FOI�IVi`
NCAC 15A 8G .0201 ,
Press TAB to enter information
Permittee Owner/Officer Name: Seven Cedars MHP/David Millsaps ij F ,-C_ t_ iA., OF FO -
Mailing Address: Village Drive Phone: [phone]
City: Statesville State: NC Zip. 28677
Email Address: [e-mail]
Signature: Jo—1
Facility Name: Seven Cedars MHP WWTP
County: Iredell
Date:
Permit # NCO023191
YOU MUST SUBMIT'A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Print Full Name Deni
Work Phone:
Certificate Type: WW Certificate Grade: III Certificate # 7144
Email address; dM� dock a_envirolinkinc.corn
Signature: t —[, Effective Date: -
"/ 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 asset 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 White Work Phone: [phone]
Certificate Type: WW Certificate Grade: 11 Certificate #: 991976
Email Address: cwhite [e-mail]
Signature: ---'- Effective Date: --1 1 �/
"I certify that I agree to my designation as a Back-up Ctperotor in Responsible Charge for the facility noted i understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC os 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."
Mail, fax or email WPGSOCC 1618 Mail Service Center, Fax: [phone] Email.
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa; NC 28778
Fax [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 29405-2845 Winston-Salem, NC 27105
Fax:;252-946-9215 Fax.,910-350-2004 Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: Seven Cedars MHP WWTP Permit #: NCO023191
BACKUP ORC
Print Full Name: Todd Robinson Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 989809
Email Address: trobinsorita)envlrolinkinc.com
Signature: Effective Date;''`/ /ca
"l certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted, l 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: David Millsaps Work Phone: [phone]
Certificate Type WW
Email Address: [e-mail]
Certificate Grade: (i Certificate #: 11777
Signature: e9� Effective Date: "
"I certify that/ agree to my designation as a Back-up 0rperotor 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 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: Marc Nault Work Phone: [phone]
Certificate Type: WW Certificate Grader I Certificate #: 9656
Email Address: [e-mail]
Signature: W� Effective Date: -119
"I certify that l agree to my designation as a ack-up Operator in Responsible Charge for the facility noted: /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 foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name:
Certificate Type: Select
Email Address:
Signature
BACKUP ORC
Work Phone
Certificate Grade: Select Certificate#
Effective Date:
"1 certify that t 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

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
=: �=
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: Lake Norman Woods WWTP {
Mailing Address: PO Box 321 '828''47&3179F i
City: Sherrills Ford
State: NC
zip: 28673
Email Address: [e-mail]
Signature: Z�)aA /vDate: April 15, 2019
Facility Name: Lake Norman Woods WWTP
County: Catawba
Permit # NCO071528
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: 11
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Dennis Murdock Work Phone: [phone]
Certificate Type: WW
Email Address:
Signature:
Certificate Grade: III Certificate #: 7144
"I certify that l 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."
BACKUP ORC
Print Full Name: Robert White Work Phone: [phone]
Certificate Type: WW
Email Address: Cwh.
Signature:
rolinkinc.com
Grade: 11
Certificate #: 991976
Effective Date: q — C' _ / 9
"l certify that / agref try designation as a Back-up Operator in Responsible Charge for the facility noted, l 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: eer"tai rn;n,,
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US 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]
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) Page 2
Facility Name: Lake Norman Woods WWTP Permit #: NCO071528
BACKUP ORC
Print Full Name: Todd Robinson Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 989809
Email Address: trobinson@en�virrolinkinc.com q
Signature: �G d/sa'Jr ems—'" Effective Date:
"I certify that / 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 asset 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: Marc Nault Work Phone: [phone]
Certificate Type: WW
Certificate Grade: Ii
Email Address: [e-mail]
Certificate #: 9656
Signature: f,.- �j„„%�- Effective Date:
"/ certify that/ 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
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective 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 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
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"I certify that/ agree to my designation as a Back-up Operator in Responsible Charge for the facility noted l 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

0
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC) tE��
NCAC 15A 8G .0201 , to f' 1
Press TAB to enter information
Permittee Owner/Officer Name: Rowan -Salisbury Schools/Tim Pharr
Mailing Address: 3078 Shue Road Phone: [phone]
City: Salisbury State: NC zip: 28144
Email Address: [e-mail]
Signature:
Date: y_129 - /I
Facility Name: Knollwood Elementary School WWTP Permit # NCO034703
County: Rowan
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
I Facility Type: I WW
Grade:
Print Full Name: Todd Robinson
Certificate Type: WW
OPERATOR IN RESPONSIBLE CHARGE
Certificate Grade: IV
Email Address: [e-mail]
Work Phone: [phone]
Certificate #: 989809
Signature: Y tom•--- Effective Date: y.- Z-19
r
"1 certify that I agree to my designation as the 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."
BACKUP ORC
Print Full Name: Robert White Work Phone: [phone]
Certificate Type: WW
Email Address: cwh
Certificate Grade: II
Certi#icate #: 991976
Signature: ,/�"-"'"� J_ Effective Date: q —1 _/
"I certify that 1 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 asset forth In 15A NCAC 08G .0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certiflcotion Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: cc i iad�ri;7r�a,7cflenr.gcv
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax:[phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: 91OA86-0707
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone:[phone] -
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd,
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Fax; 336-776-9797
Phone:[phone] Phone:[phone] Phone.,336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone;919-791-4200
Revised 4l2016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: Knoliwood Elementary School WWTP Permit #: NCO034703
BACKUP ORC
Print Full Name: Dennis Murdock Work Phone: [phone]
Certificate Type: WW Certificate Grade: III Certificate #: 7144
Email Address: [e-mail]
Signature: Effective Date:
"Icertify 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."
BACKUP ORC
Print Full Name: Marc Nault Work Phone: [phone]
Certificate Type:
Email Address:
Signature:
Certificate Grade:
Certificate #:
Effective Date: Zi-" �1
1 certify that i agree to my designotlorf`as a Back-up Operator in Responsible Charge for the facility noted. l understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC asset 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:
"I certify that 1 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 faiNng 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
Email Address:
Signature:
Certificate Grade: Select
Certificate #:
Effective 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 ORC as set forth in 15A NCAC 08G .0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 4I20l6