NC0036269_Other_20190923

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
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Facility Name: WATER &SEWER AUTHORITY OF CABARRUS COUNTY Permit # WQ0032332
Facility Type: LA Facility Grade: IV SUBMITASEPARATEFORMFOREACHCLASSIFICATION
Permittee Owner/Officer Name: Travis Mark Fowler
Email Address: mfowler@wsaccI
Permittee Signature:
ORC
Operator in Responsible Charge
Full Name: James Christian Sims
Email Address: [e-mail]
Date:
Work Phone: [phone]
Certificate Type: LA Certificate Grade: NSA Certificate #: 1002028
Signature: // _ _ Effective Date: `� 1 % � �
"I cer ' that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. I under tand and will
obi e 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
Full Name: Karen Renee Marie ([e-mail]) Work Phone: [phone]
Certificate Type: LA Certificate Grade: NSA Certificate #: 1002612
Signature: Effective Date: U
"I certify that I agree to my nation as a Back-up Operator in Responsible Charge for the facility oted. 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 can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"1 certify that I agree to my designation 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 OSG .0204 and failing to do
so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 � FAX: [phone] [e-mail]
Mail or fax a COPY to: I Mooresville-610 E. Center Ave., Suite 301, Mooresville, NC 28115 � FAX: [phone] � PH: 704-663-1699
Revised 312019