NC0021181_Other Agency Documents_20190626

Date: (�_t 6j 1
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Facility Name: x t ( m a
NPDES Permit Number: N I C 161 o 12 I l I 1 I S I I I
To Whom It May Concern:
JUN 2 - M9
WOR S
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 213.0506.
Individual # 1
Individual #2 (if applicable)
Name:
e- ,� c
.S e
g
Title.
//js�7
l./ rL�
/ P L4 f 0� 4 M A 4-
/ 1
I� r1 t t l 1 T
Mailing Address:
L1a 8� T L.,
Be-(M0 vC. rf0l
zJ q I L 4 (, <
/W4- 1Ya(),
lam; 4 Z DP .
ivc z /2
Physical Address:
(if different)
Email Address:
+ e z e. e. t t 6�- 6 c i f. CAI . o
c, r,
Office Phone:
7U _ 6-1 r - 3'7 `t 1
Mobile Phone:
I _ q y L(,3
O q) -Z S-'o ` 7 Co S 3
If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below.
Sincerely,
Authorized SigningOfficial's Signature
Authorized Signing Official's Name (type or print) Title
Mailing Address
6 nn',( l e ,- A� C i ' (I lac /n, �,-, . ® rg
mail ddress
6
Office e Phone Mobile Phone
cc: )A o o < < i v j Ile Regional Office, Water Quality Permitting Section
(Enter region natne) I
5

NCAC 15A 8G .0201 UN 2 6 2
Press TAB to enter information
Permittee Owner/Officer Name: Adrian Miller W€ ROS
Email Address f [e-mail]
Xa
I
Permittee Signature:
Facility Name: Belmont WWTP
Date: //
Permit # NCO021181
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: IV
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Tanya Setzer Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 1005913
Email Address: [e-mail]
Signature: UaZlEffective Date:(P la,� G9
"I certify that I agree to my de ignation 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 7771
Print Full Name: Daniel Perry Work Phone: [phone]
Certificate Type: WW
Certificate Grade: III
Email Address: [e-mail]
Certificate #: 1008159
Signature: _ �� 4��,,4,i , A-t �J C L Effective Date: l `2 U�`Z 0 ! �j
r
"l 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
ORIGINAL to:
Mail or Fax a COPY to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail] Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mail
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 Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone:[phone]
Revised 512019

Date: 6 ,_ � j 1
11JNI 2 601
Wastewater Branch wom
Water Quality Permitting Section Mi"ORESVI r E RED IONAt_ Or [Aer,'
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature uthority
Facility Name: &�-
NPDES Permit Number: N I C 101®12 I i I 1 I S 1 1 1
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1
Individual #2 (if applicable)
Name'
g
Title.
Cj
/ rcffE.iM.� l
Mailing Address:
Q tC
V` T (c C.- u c �-
0-1"10 L oZ fr®I`z
�..7 q I L. a iG l
11
�; J T 4 Qr
Physical Address:
(if different)
Email Address:
+ -L cr a C_ i 6(OC I A-04 . d
e.-.- � G e i a (� a ��. 6A 1 . o
Office Phone:`
O q k - z r - .37
Mobile Phone:
-� q 113a g c j q
G y Z SO (( 3 3
If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below.
Sincerely,
Authorized Signing Official's Signature
Authorized Signing Official's Name (typeorprint)
�� f�r�x �31 C{ � l✓Y,hr�
Mailing Address
Title
mail ddress I
76
Office Phone Mobile Phone
cc: Moo < E a v j Ile Regional Office, Water Quality Permitting section
(Enter region name)
5