WQCS00257_Other_20190918

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: C ( A, (C I9
Email Address: t i (,q
Permittee Signature:
Facility Name: Town of Maury
Date: 5;�_j
Permit # WQCS00257
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: CS
Facility Grade: I
I ORC - OPERATOR IN RESPONSIBLE CHARGE SA ow-7
0
Print Full Name:
J
J I�rRC i/ K� e 2 5'
Work Phone:
Certificate Type:
Select
Certificate Grade: Select
Certificate #:
210
Email Address: A/
Signature: ; Effective Date:
"1 certify that / ogre4 my design io th perator in esponsible Charge for the facility noted. I understand and will abide by th
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 i
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: SOS Q,p y D ot1g L k e06Q -,+s Work Phone:
Certificate Type: CS 0 Certificate Grade: I) 0 Certificate #: 1004220
Email Address: [e-mail]
Signature: Effective Date:
"/ certify that / agree to designation as a Back-up O erator in Responsible Charge for the facility noted. / understand and will abide b
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 i
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
Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville
2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]R
Phone: [phone](
Revised 52G