WQ0012696_Owner (Affiliation Change)_20220913

North Carolina Department of Environmental Quality
Division of Water Resources
Permit Number: WQ0012696
Permit Type: Wastewater Irrigation
Facility Name: Pamlico River Ferry Terminal WWTF
Facility Addressl: 229 NC 306 N
Facility Address2:
City, State & Zip: Bath, NC 27808
Owner Information Details:
MUST submit a Change of Name/Ownership form to DWR to make any changes to this Owner information.
(Click here for "Change of NamelOwnership "form)
Owner Name: North Carolina Department of Transportation - Ferry Division
Owner Type: Government - State Owner Type Group: Organization
*** Legally Responsible for Permit ***
(Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor,
or any other person with delegated signatory authority from the legally responsible person.)
Owner Affiliation: -Laoflavtd Qha(r Title:
Addressl: 159 Lucinda Ln
Address2:
City, State & Zip: Powells Point, NC 27966-2520
Work Phone: 2&2-333-7 6� 2 5 2 --7 2 5 - 3 $7 l Fax: [phone]
Email Address: + dgtiocr 0nc do} • -o- [d�ee�t� ncdo • 9ov %vr9ej;�an�®
*** Permit Annual Fee Billing ***
Billing Month: November
Invoice Number Invoice Date Invoice Due Date Invoice Amount Invoice Status
Owner Contact Person(s)
Contact Name Title Address Phone Fax Email
Catherine Peele 159 Lucinda Ln, Powells Point, NC 'e' nn+ 'C'
27966-2520
Facility Contact Person(s)
Contact Name Title Address Phone Fax Email
Dav;.d ?h)W' Kac.lrAvy 15ci the?'da Lane a152-725-3S7+ 4d61C0ef01}Cj0+.yV'
ftC tnaAGra �/`flbr
Permit Contact Person(s)
Contact Name Title Address Phone Fax Email
�\ '- \-, Ile- \\
OG Vi a PAC{
Permit Bilking Contact Person(s)
Contact Name Title I Address Phone Fax Email
4NGB9T- t;nv;ronm"l 159 Lucinda Ln, Powells Point, NC Q
Rf'an no l: %%( 5upUL5er 27966-2520 2 '5i a - 6 2) -625) 6c do1AD&
12/19/2022

Permit Number: WQ0012696
Permit Type: Wastewater Irrigation
Facility Name: Pamlico River Ferry Terminal WWTF
Facility Addressi: 229 NC 306 N
Facility Address2:
City, State & Zip: Bath, NC 27808
Persons with Signatory Authority
ape Contact Name Title Address Phone Fax Email
Owner _ 159 Lucinda Ln, Powells Point, 252 ___ VrdVM
Permit Brian Doliber 159 Lucinda Ln, Powells Point, 252-621-6251 [e-mail]
NC 27966-2520
Designated Operators
If the designated operators listed below are incorrect or no longer associated with the collection system, the information can be updated by su
a completed "Operator Designation Form"(Click Here for ORC Designation Fonni please provide specific details as to the changes requested, r
the additfon/removal of designated operators. For all other operator questions or issues, please call 919-807 6353.
Facility Classification: SI
Operator Name
Role
Cert Type
Cert Status
Cert #
Effective Date
Larry Burgess Lupton
Backup
SI
Active
21094
1/22/2002
add- OQ,rd ehq(r
ORG SL. ACA" Yz alto)

ROY COOPER
MICHAEL S. REGAN
LINDA CULPEPPER
Water esourre.-
EN M0NMFN_sAL GUAUI
PERMIT NAMEIOWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
waoo1 a6a6
Permit Number: NCOQ / / 1 / or NCGS / / / /
1. Facility Name: faini,co &*,c h(ru Ttrm;ng' WW/TP
Il. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only __X_c. Other (please explain): GhAn* if) f`e5©nA5ib1f, 0� c;al Al,O
2. New owner's name (name to be put on permit):
Da,►;a Phar c
3. New owner's or signing official's name and title: Dm f 7 P)n0, cc
(Person legally responsible for permit)
Ij (Title)
4. Mailing address: 15 q I-vc,; nAa LO►nf. City: P12VV211s PO 70+_
State: I)(/
E-mail address:
Zip Code: a 7 91Phone: ( 9.5 A) 7 a 5- 3371
WVIIt ✓s
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION U
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina ( Environmental Qualitv J Water Resources
1617 Mail Service Center ( Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.ne.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/updes-wastewater-permits
11J0 , j0✓

NPDESName & Ownership Change
Page 2Df2
A41� . attest that this ;;nn1irifinn fnr q
name/ownership change has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this application are not completed and that
if all required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature:--- Date:
- 1��Lc
—4z
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2O17

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: North Carolina Department of Transportation
Mailing Address: 159 Lucinda Lane
City: Powells Point
Email Address: [e-mail]
Signature:
Facility Name: Pamlico River Ferry Terminal WWTF
County: Beaufort
Phone: [phone]
State: NC Zip: 27966
Date:
Permit # WQ0012696
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
I Facility Type:IS[
Facility Grade: I Select ?
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: David Pharr Work Phone: [phone]
Certificate Type: SI
Email Address: [e-mail]
Signature
Certificate Grade: Select
Certificate #: 21101
Effective Date:
"I certify that l agree to my designation as the Operator in Responsible Charge for the facility noted. / understand aA 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: Larry Lupton Work Phone:
Certificate Type: SI
Email Address: Imisc@embarqmail
Signature
Certificate Grade: Select
Certificate #: 21094
Effective Date: //`
"9 certify that l agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understo d and will abide by
the rules and regulations pertaining to the responsibilities of the ORC asset 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 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
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: [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 Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016