NCG110150_Renewal COC Request_20190522 12:33:13 PM

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NORTH CAFOLINA
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Permit COC
NCG110150
Number *
Enter the Certificate of Coverage (COC) number, not the General Fbrmt number (e.g., NCGO30222 is the COC, not
NOG030000) M-ST BEGIN WTTH CAFTTAL "NCG'
Name of Person
Brent Dean
Obtaining COC*
First and LastNarre
Phone Number* 9102847969
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email [e-mail]
(Optional) Enter an additional email address to whom to send the COC
Please review the information below for accuracy before submitting. If there are inconsistencies, please
contact Bethany Georgoulias at [phone] or [e-mail].
Master General NCG110000
Permit No.
COC No.
NCG110150
Permittee
Town of Wallace
Facility Name
Wallace Regional WWTP
Address
851 Old Wilmington Rd
City
Wallace
County
Duplin
Waterbody
Rock Fish Creek (New Kirk Pond)
Classification
C;Sw
River Basin
Cape Fear
RENEWAL STATUS
Active
Issuance Date*
05/31/2018
Effective Date
06/01/2018
1 hereby request a copy of the Certificate of Coverage (COC) entered above. I understand that the COC e-mailed as a
result of this request will serve as the Permittee's record of renewed coverage under the General Permit, and that this
record must be maintained with the Permittee's NPDES Stormwater Permit records.
Signature *
Mat peok

Date * 05/22/2019