NC0026441_Operator Designation Form_20190610

WatCTollution Control System OperA(—)Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
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Mailing Address: C) boy, --w q
City: .1-C-0a. State: A(- Zip: Q23'-- Phone #: Gi 1) `1�ia- Lj 3
Email address:
Signatures Date: G ba I i�
.................................................................................................................................................
Facility Name: nzC S ; l-s C Jlr 1-.3L-Z' 4 � Permit #: J*JL-60oq
County:_ ("6AL-"�rA _
........................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM.'
Facility Type/Grade (CHECK ONLY ONE): �.
Biological Collection Physical/Chemical Surface Irrigation Land Applicatiod „
..............................................................................................................................................d
Operator in Responsible Charge (ORC) .
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Print Full Name: f '�'/ Ya r A&.- Email: ark .S f early .0a
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Certificate Type I Grade / Number: LO LO I L4 00 R Work Phone #: F19.' _
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Signature: Date:
"I certify that agree to my, des ation 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-"
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Frill Name: L- Email: f L sI' I -et- GT . D
Certificate Type / Grade / Number: V&D 160 4 71 L. Work Phone
Signature: Date:
"I certify that 1 agree to my designation as a Back-up perator 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."
............................................................................................................................................
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
2dE ne to: Eta: certadmin(a)ncdenr eov
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
appropriate Regional Office. 2090 US Hwy 70
225 Green St
610 E Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W, Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax.[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Raleigh
3800 Barret) Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-205
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0
li"PCSOCC Operator Designation Form, cony.
Facility Name: wi Permit M
.......................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Pull Name: Lh r; S MQz_,n,t1,,,Ve i4 Email: in Lx �, tAr
Certificate Type / Grade / Number: 3 Work Phone #:
Signature: h2 LAU Date:__0_(a_/ to Levu?
`9 certify that I agree to my designd 11 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 I SA 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:
Email:
Work Phone #:
Signature: 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 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:
`9 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 fortb 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