NCG100136_Renewal COC Request_20200430 10:25:10 AM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG100136
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General P n-rit nurrber (e.g., N00030222 is the ODC, not
NCG030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
Stephen Foss
Obtaining COC*
First and Last Name
Phone Number* [phone], EA. 5500
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 CDC
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.
NCG100136
Permittee
Robert Young
Facility Name
109 U Pull It Used Auto
Address
3459 Thomasvillle Rd
City
Winston Salem
County
Forsyth
Waterbody
Fiddlers Creek
Classification
C
River Basin
Yadkin
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 * 04/30/2020