NCG070139_Renewal COC Request_20180813 4:57:53 PM

Environmental
Quality
Permit COC
NCG070139
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
Maria Ellis
Obtaining COC*
First and Last Name
Phone Number* 2524921061
Email * [e-mail]
The COCwill be e-mailed to this contact.
Additional Email (Optional) Enter an additional eneil 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].
M aste r Ge ne ral
NCG070000
Permit No.
COC No.
NCG070139
Permittee
Ellis Septic Tank
Facility Name
Ellis Septic Tank -Vance
Address
399 Garrett Rpad
City
Henderson
County
Vance
Waterbody
Sandy Creek (Fox Reservoir, Roland Pond,
Club Pond, Weldons Mill Pond, Southerlands
Pond)
Classification
C;NSW:+
River Basin
Tar -Pamlico
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 Storni Permit records.
Signature *

Date * 08/13/2018