NCG110013_Renewal COC Request_20180626 7:45:00 AM

JI
Environmental
Quality
Permit COC
NCG110013
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit number (e.g., NOG030222 is the OOC, not
COC No.
NOW30000) MUST BEGIN WITH CARTAL "NO3'
Name of Person
Jon Southern
Obtaining COC*
First and Last Name
Phone Number* 336-397-7600
Email * [e-mail]
The COCwill be e-mailed to this contact.
Additional Email (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.
NCG110013
Permittee
City of Winston-Salem
Facility Name
Archie Elledge WWTP
Address
2801 Griffith Rd
City
Winston Salem
County
Forsyth
Waterbody
Salem Creek (Middle Fork Muddy Creek)
Classification
C
River Basin
Yadkin
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 *
Date * 06/26/2018