NC0036196_Other Agency Documents_20190701

Water Pollution Control System Operator Designation Form
WPCSOCC JUL
NCAC 15A 8G .0201
WOROS
Permittee Owner/Officer Name: Tam 9 S
Mailing Address: j&/ 95 D
City: N ctv State:ll(— Zip:
Email address:
Signature:
N
Phone #: 6q 5 " q,3)0
Date: G
........................../.....................................................................................................................
Facility Name: CIL o � 61,wk ek� ivt,7p Permit #: �� �� (�% tP
County: (ATAwfl.A
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Jy+m e 5 URl L jo-,,-PS Email:'IrV_ n�? f (? Aef-v aC, PLI
Certificate Type / Grade / Number — �d�l Work Phone #: 5ZS 6 % 5�— '13 % O
Signature: Date:!
"I certify that I agr o my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pert ining 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 Full Name: 5CCrf-r I.NOtS YArI SQL Email:
Certificate Type / Grade Number: WI-4* '9%550i5i Work Phone #:
Signature: Date: tO Z!� 2019
"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 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]
original to: Email: certacimit ki-h- r 0
Mail or fax a copv to the Asheville
appropriate Regional Office: 2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
Mooresville
Raleigh
225 Green St
610 E Center Ave
3800 Barrett Dr
Suite 714
Suite 301
Raleigh 27609
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Wilmington
Winston-Salem
127 Cardinal Dr
450 W. Hanes Mall Rd
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015

TVPCSOCC Operator Designation Form, cont.
MOO` ESVILLE RIEGIt NIAL,O OFFICE--
Facility Name: C; LA'Xte CRCGIG WWI Permit #: W-00"M019 b
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: S� G q i{cl�L? Email: mi '2�i i i1 7 , -C - ��V
Certificate Type / ade / Number: �'VV
-_ I ? 5 Work Phone #: _ 13 37
Signature: Date: _
"I certify that I agree to my desib ation 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: L,4WM ►� ��G�s, L,. Email:
Certificate Type / Grade / Number:Work Phone #: -- t 5 q 2
_® ---- —
Signature: k , � Dater ' %' /
"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 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: J�1 Vty Lee I-46,S Vo ✓4 Email: 4/ .4 S L4✓O 60 %i e v g° `7. ' y
Certificate Type /Grade /Number:
(A) �2j 1 J D (0 �331 Work Phone #: — 6a 15— 4" L o
Signature: V 1 — Date: °� �z
"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 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: AeVif )� Email: AAjj g I1e'f,,/-d,i(. !1.C,l
Certificate Type / Grade / Number: MAY "3 kcb,73 Work Phone #:
Signature: � X �! c? Date: �� -,;; % ' �%Z
"I certify that I agree to m 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."
Revised 05-2015