NC0074306_WPCSODF_20190806

2019-08-06 18:21 FC water treatment 8282485227 >> 828 299 7043 P 1/1
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Town of Forest City
Mailing Address: PO Box 728
city: Forest City
Email Address: [e-mail]
Signature:
Facility Name: Forest City Water Treatment
County: Rutherford
Phone: [phone]
State: NC zip; 28043
Date:
Permit # NCO074306
YOU MUST SUBMIT SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: PC
Facility Grade: 1
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Andy Carl Wells Work Phone: [phone]
Certificate Type: PC Certificate Grade: I
Email Address: [e-mail]
Certificate #: 1007513
Signature: ��w 0,0,0 ( A )QDL Effective Date:
"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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Jesse Stephen Hill Work Phone:[phone]
Certificate Type: PC
Email Address:
Certificate Grade: I
Certificate #:1006660
Signature: le. Z24,I^ Effective Date: ?A0// of
"I certify that I ogres o 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 1SA NCAC 08G.0204 and foiling to do so con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax:[phone] Email: certadmin@nedenr,gov
ORIGINAL to: Raleigh, NC27699-1618
Mall or Fax Asheville
a COPY to: 2090 US Hwy70
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;910.433-3300
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
MooresvillC
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax:[phone]
Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone: [phone]
Revised 412076