NC0000272_Operator Designation_20190401

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Wallace McDonald
Mailing Address: 175 Main Street
city: Canton
Phone: [phone]
State: NC Zip: 28716
Email Address: [e-mail]
Signature:
Facility Name: Blue Ridge Paper Products WWTP
County: Haywood
Date: ) gii l9
Permit # NC0000272
4
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YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION qF SYSTEM:
Facility Type: WW 0
Facility Grade: IV 0
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Tracy James Willis
Certificate Type: WW
0 Certificate Grade: IV
Email Address: [e-mail]
APR
3 2019 t.
Water Ouailh,., r c-^ , or -:orations
Work Phone: [phone]
Q Certificate #: 998768
Signature: , Effective Date: A/
"/ certify that i agree to my esignation as the Operator in Responsible Charge for the facility noted. I unders a d 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: Philip Lynn Teague Work Phone:[phone]
Certificate Type: WW
Certificate Grade: IV El Certificate #:994359
Email Address: [e-mail]
Signature: �1 , Effective Date: ►-� j j % j �j
"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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
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: Blue Ridge Paper Products Inc. WWTP
Permit #: NC
APR j >019
BACKUP ORC
Print Full Name: John J. Pryately Work Phone:[phone]
Certificate Type: WW
D Certificate Grade: IV 0 Certificate #:14109
Email Address: [e-mail]
Signature: Effective Date:
"/ certify that/ agree o my designation as a B ck-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: 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. / 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:
"/ certify that / agree to 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."
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. 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