NC0023001_WPCSODF_20190620

Water Pollution Control System Operat g}ekjip�pq
WPCSOCC
NCAC I5A 8G .0201
Permittee Owner/Officer Name: Carolina Water Service of NC II IN 9 Fj 2nig
Mailing Address: 4944 Parkway Plaza Boulevard Ste. 375
Water Quality Regional Operations
City: Charlotte State: NC Zip: 28217- PhonA$hQ1Cd RtP i EIDaisg
Email address: [e-mail]
Sign a Date: _1 EO�_]_�_-
Facility Name: 'LA& (�,q.J Rc's 0 Mr Permit #: OC 00m? 3 OV I
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological W WTP _11C Surface Irrigation
Physical/Chemical Land Application
Collection System
................................................................................................................................................
Operator in Respon§ible Charge (ORC)
Print FOIL Name: 1ptl t.. "o X M u Ap pF7l
Certificate Type /' Grade
ms/ Number: W t � 7 5 Sl U Work Phone #: ( Safi) to M M S D to to
Signature: Date: &
`9 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 Full Name: /4'44ita fARRE4s_ ST9RNC4
Certificate Type / Grade / Number. 6J Q/-T 0 08'013 Work Phone #: (9'4e) 6 */'P-S-6 G 4
Signature: (iLGLtfcti' Date: & "1 9'1 cj
"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: certadminknedenr.eov,
Mail or fax a copy to the Asheville
appropriate Regional Ofce: 2090 US Hwy 70
Swanmmoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]"
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Or
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 02-2013