NCG060235_Renewal COC Request_20181203 5:22:07 PM

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NORTH CAFOLINA
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Permit COC
NCG060235
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 CAFTTAL "NOG'
Name of Person
Robert Pawelczak
Obtaining COC*
First and LastNarre
Phone Number* 919-779-5252
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].
M aste r Ge ne ral
NCG060000
Permit No.
COC No.
NCG060235
Permittee
Domino's Pizza Distribution
Facility Name
Domino's Pizza Distribution
Address
3100 Waterfield Dr
City
Garner
County
Wake
Waterbody
White Oak Creek (Austin Pond)
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 * 12/03/2018