NCG100197_Renewal COC Request_20210823 8:11:20 AM

Permit COC NCGlOO197
Number * Enter the Certificate of Coverage (OOC) nun ber. MIST BEGIN WTTH CARTAL "NOG'
Please review the information below for accuracy before submitting. If there are inconsistencies, please contact
[e-mail], or check the box below that says "permit information is incorrect".
Permittee * Pull -A -Part, LLC
Facility Name Pull -A -Part of Winston-Salem, LLC
Address 4117 N Patterson Ave
City Winston Salem
County Forsyth
Name of Person Lance Layton
Requesting COC* First and LastNarre
Phone Number* 770-500-5366
Email * [e-mail]
The COC w ill be e-nailed to this contact.
Additional Email [e-mail]
(Optional) Enter an additional email address to whom to send the ODC
Master General Permit NCGl00000
Issuance Date 06/30/2021
Master General Flarrrit Issuance
Effective Date 07/01/2021
Master General Permt fffective
NOTE: You can verify the COC facility information and renewal status by running this Permit Summary Report (check the
Permit Status at the top of the report). If the permit is expired, a renewal COC will not be available. This may be
because fees are owed. You can check for outstanding invoices at https://deq.nc.gov/sw-epayments.
V I am requesting a copy of the renewal COC.
« Do not check this box below unless you verified the COC is e)pired with the report above. »
r the COC is still expired, but owed fees have been paid.
r- permit information is incorrect or old.
I 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. If a COC is not available, I request a
follow-up from Stormwater Program staff.
In addition, I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act"); and I agree to conduct this transaction by electronic means
pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act").

Signature *
&Alew
Date * 08/23/2021
Time 08:11:20 AM
If you do not receive an email with a copy of your renewal COC within a day, please contact
[e-mail] or [e-mail]