NC0020389_Other_20190103

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Water ])ution Control System Operatonsignation Form,/
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WPCSOCC 011114/
NCAC 15A 8G .0201 4/elg� ?�,9 R, y
Permittee Owner/Officer Name: Mr. Matthpw_ Zaps } Town Manager
Mailing Address: Post Office BOX 69 OfCIc+
City: _Benson State: NC Zip: 27504 v,_ Phone #: [phone]
Email address: _ mzappC towndbenson.eom_
Signature: Date: 12/31/2018
Facility Name: Town of Benson WWTP Permit #: NCO020389
County: Johnston
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM?
Facility Type/Grade (CHECK ONLY ONE):
Biological I Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Steve A. Procter Email. [e-mail]
Certificate Type / Grade / Number: WW 4 #26527 Work Phone #: [phone]
Signature: U ., 8 � _ Date: 01/03/2019
"1 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 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 lull Name: Brian P. Leavitt
Email: bleavitt_.town ofbenson.com
Certificate Type / Grade / umber: WW- #1006366 Work Phone #: [phone]
Signature: Date: 01 /03/2019
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 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,"
..................................................................................................................................................
Marl, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
oriubt to: Email: certadminna ncdenr.eov
!Mail or far a coop to the
Asheville
Fayetteville
Mooresville
Raleigh
appropriale Regional Office:
2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
R:Icigh 27609
Fax: [phone]
Fayetteville 28301-5W
Mooresville 28115
Fax: [phone]
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[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]
Revised 05-2015