NC0020389_Other_20190530

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Water ollution Control System Operatnesignation Form
WPCSOCC
NCAC 15A 8G r0201
Permittee Owner/Officer Name: Frederick D. Nelson / Interim Town Mana er
Mailing Address: Post Office Box 69
City: Benson State: NC Zip: 27504 - Phone #: [phone]
Email address: fnelson0townofbenson_com
Signature: 00--i9le, 01
�ai�llll , Date:
Facility Name: Benson VWVfP Permit #: NCO020389
County: Johnston
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SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
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Facility Type/Grade (CHECK ONLY ONE):'.
Biolo ical Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
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Print Full Name: Brian P. Leavitt Email: bleavitttc7l,�townofbenson.com f°
Certificate Type Grade / umber: -4 #1006366 Work Phone #: [phone]
Signature: Date: s/31) // j
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I undcrstand and will abide by tile rules
and regulations pertaining to the responsibilities ofthe 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: Steve A. Procter Email: sprocter townofbenson.com
Certificate Type / Grade I Number: WW-4 #26527 Work Phone #: —919-8/94-2373
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Signature: Date:a__i Fj
"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 ofthe 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."
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Afail, fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
oririnal to: Email: certadmin0mcdenra my
Avail or fax a coop to the Asheville
Fayetteville
Mooresville
appropriate Regional Office: 2090 US Wtvy 90
225 Green St
610 E Center Ave
Stvannanoa 28?78
Suite 714
Suite 301
rax: 828.299.7043
Fayetteville 28301-5043
Mooresville 28115
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sy Mail
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 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
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Revised 05-2015