NC0081621_Email_20190826

A�g.23.2019 3:29PM No.0351 P. 1
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
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Permlttee Owner/Officer Name: Travis Mark Fowler
Mailing Address: 6400 Breezy Lane
city: Concord
Phone: [phone]
State: NC Zip: 28025
Email Address: [e-mail]
Signature: —a-ti Date:
Facility Name: Muddy Creek Wastewater Treatment Plant
County: Cabarrus
Permit# NCO081621
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
0
Faclllty Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Kimberly D. Holt Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV Q Certificate #: 993802
Email Address: [e-mail]
Signature: , A EffectiveDate: X—/g—/1
"I 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."
BACKUP ORC
Print Full Name: Braden Joshua Cook work Phone:[phone] X118
Certificate Type: WW 0 Certificate Grade: IV Certificate #:1002815
Email Address: [e-mail]
Signature:\L Effective Date:
"I certify that I agree to my de
signotion as a Back-up Operator in Responsible Charge for the facility noted. 1 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 con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mall Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mall or Fax Asheville Fayetteville Mooresville Raleigh
a COPY to: 2090 US Hwy 70 225 Green St., Sulte 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115 Raleigh, NC 27609
Fax!828-299-7043 Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone!910-433-3300 Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mall Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] Ravlsad4/2ote

A�g.23.2019 3:29PM
No.0357
WPCSOCC Operator Designation Form (continued)
Facility Name: Muddy Creek Wastewater Treatment Plant
Permit #: NCO081621
Page 2
BACKUP ORC
Print Full Name: Karen Renee Marie Work Phone:[phone] X118
Certificate Type: WW
Email Address: [e-mail]
0 Certificate Grade: IV 0 Certificate #:1002612
Signature: ;� /_ Effective Date: V'-/2 /
I certify that I agree to my designation as a Bock -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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: James Christian Sims Work Phone:[phone] X118
Certificate Type: WW
Email Address: lam(
Signature:
Certificate Grade: IV 0 Certificate #:999309
Effective Date: 8- e4 /I e, _ L"
"I certify that I agrepTo my designation as a Bock -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 falling to do so can result in
DisciplinaryActlons by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Jesse Lee Wingler Work Phone:[phone] X118
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #:1004838
Email Address: [e-mail]
Signature:
Effective Date:
"I certify that I ag�to my.tfesignotion 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."
BACKUP ORC
Print Full Name. Matthew Dwayne Isenhour Work Phone:[phone] X118
Certificate Type! WW
0 Certificate Grade: IV 0 Certificate #:1002601
Email Address! misennour(wwsacc.org
Signature: Effective Date: �/j3 bg
certify that I agree to my designation as a Bock -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."
Re.sea 4/2016

A�g.23.2019 3:29PM
No.0357
WPCSOCC Operator Designation Form (continued)
Facility Name: Muddy Creek Wastewater Treatment Plant
Permit #: NCO081621
Page 2
BACKUP ORC
Print Full Name: Nicholas James Merwin Work Phone:[phone] X118
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #:1006823
Email Address: nmerwin(a)wsacc.org
Signature: �� ��{�i�j��—� Effective Date:
"I certify that I agree to my designation as a Bock -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 cis 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: Adam Neal Love Work Phone:[phone] X118
Certificate Type: WW
Email Address:
Signature:
0 Certificate Grade: III 0 Certificate #:1008206
Effective 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 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
Print Full Name: Christopher Scott Yost Work Phone:[phone] X118
Certificate Type: WW 0 Certificate Grade: II 0 Certificate #:1002797
Email Address: [e-mail]
Signature: �/Yr s�f� -1 . V%�— Effective Date:���lo
"I certify that I agree to my designation as a Back-up Aerator 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 68G.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name- Work Phone.
Certificate Type: Select 0 Certificate Grade: Select 0 Certificate #:
Email Address!
Signature:
Effective 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 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."
Revlsed 412016