NCG100124_Renewal COC Request_20190828 3:39:14 PM

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NORTH CAFOLINA
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Permit COC
NCG100124
Number *
Enter the Certificate of Coverage (COC) number, not the General Fbrmt number (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Thomas Jackson
Obtaining COC*
First and LastNarra
Phone Number* 9192662704
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 NCG100000
Permit No.
COC No.
NCG100124
Permittee
Thomas Jackson
Facility Name
Jackson Auto Salvage, Inc.
Address
7120 Poole Rd
City
Raleigh
County
Wake
Waterbody
NEUSE RIVER
Classification
QNSW
River Basin
Neuse
RENEWAL STATUS
Active
Issuance Date *
10/29/2018
Effective Date
11/01/2018
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 *

Date * 08/28/2019