WQCSD0391_Other Agency Documents_20190620

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FQ Mjjjj -
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Tony Konsul WOR013
Email Address: [e-mail]
Permittee Signature:
Date: L
Facility Name: Kings Grant Permit #
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: CS
Facility Grade: I
WQCSD0391
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Cory Fredell Work Phone: [phone]
Certificate Type: CS
Email Address: cory3fredell
Signature:
Certificate Grade: I
rolinawaterservicenc.com
Certificate #: 10006498
Effective Date: (' 1 I 0 1) 4
"i certify that I agree tomy 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: Lila BIelgh Work Phone: [phone]
Certificate Type: CS
Email Address: I . lei
Signature:
Certificate Grade: I
nawaterservicenc. com
Certificate #: 1004941
Effective Date:
"I certify that I agree to my designation as a Vc k-up Operator in Responsible Charge for the facility noted will understand and wilt abide by
the rules and regulations pertaining to the re ponsibilities 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, Raleigh, NC 27699-1618
ORIGINAL to: Emaail:'certadrnin@n denr.gb Fax: [phone]
Mail or Fax a COPY to: Asheville
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 Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800 Revised 512019