WQ0007283_ORC Designation Form_20190731

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address:
City: _
Email
Pa t3o x G�
PO kkC CJC.SyI RIC— State: tyC- Zip: Z�5
Signature:
Phone #: ZSZ ZZ4-- 1�
1-0L_- o / 1 o��5v`� I IG'
Date:
..................... .........................,.................................................................................................
Facility Name: �v L,;y,, o� I c' �/ ���c5 �,' Ile WWT(� Permit #: (� D D "7 Z 3' 3
County: J-v^e s
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONL ONE):
Biological Collection Physical/Chemical Surface Irri ation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Joy-+ti ti, ESC4-'c1c="1c:l`c- 3kmail: S ��"' � ec_ i"r. GoM
Certificate Type / Grade / Number: I S '_-1 q C> Work Phone #: 2�S 2 to 1-7 1 Lcl 9 Z
C.S - 3 8 to
Signature: Date: 9 i 1 I Z-0 19
"I certify tha agree to my des' ation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to a responsibilities of the ORC asset 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: /ate
Email: �Gwk%'-l.s 4- (/�hewbe_�­)h1C_ - Av
Certificate Type / Grade / Number: / D 9 y Work Phone #: 2_r2. 4 3
Signature: K Date:
"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: certadmin(i ,ncdenr.zov
Mail or fax a com to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: Do
Mailing Address: PQ /3ox
-,/ off` t`96 /I
City: lr,6 //ac_Cs0 t_. Le State:/uG Zip: 2��3
Email
Signature:
Phone #: zs'2 z z4 —
/lOcxSU L4 C Q_ cc-m
Date:
.................... I..............................nn...............................................................................................
Facility Name: I-r—O wV� o f 1`a l % oak s v; %fie wT Permit #: U-)Q 0 0o -7 Z ?3
County: J vW-e s
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collectio Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name:Email: I ec _ rT- Cyr
Certificate Type / Grade / Number: C S G38 [oG Work Phone #: ZSZ fog I —((09 Z
ellSignature: Date: E5
"I certify that I agree to my de ation 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:__r_c_,�c Email: o✓
Certificate Type / Grade / Number: 6-s,)e y 2 S 7 Work Phone #: z S'2- 6 3 9— 7,1-rf-
Signature: I'1- Date: 7-- 3
"I certify at 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: certadminna,ncdennzov
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name
Mailing Address:
City: 1*::6 I t c 7 It l G
Email address:
j-=;, V
State: tiX-- Zip: 0­5's3-
Phone #: Z-S Z
Facility Name: vw" a f Igo / / 0 e-ks v> 1 % L Aj W TP Permit #: W L� D D O 7 'Z ?3
County: $
.................................................................................................................................................
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: S Email: J ��d `J" `�`1 @ �c • ►—r- cam
Certificate Type / Grade / Number: �e Z �q 5�', CT Work Phone #: 2
Signature: Date: a 1 l 2c7 l q
"I certify that I agree to my 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."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Ti�v i2 14 ct wtrl , S Email: kg - k � - S t- 19 P)e k4er l N 4L , Sc? V
Certificate Type / Grade / Number: 6- raJe W / 5 5 0 F 2- 2 Work Phone #: 25-2 -- G 3 S — % J',r"J
Signature: ", kL Date: 7 — 3 / —/ 5
"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: certadminna,ncdennizoy
Mail or fax a copy to the Asheville
Fayetteville
appropriate Regional Office: 2090 US Hwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax: [phone]
Fayetteville 28301-5043
Phone:[phone]
Fax:[phone]
Phone: [phone]
—Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax:[phone]
Phone:[phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Revised 05-2015