NCG100040_Renewal COC Request_20181207 2:54:11 PM

'rl n
NORTH CAFOLINA
Emlre -.1 Qd Wy
Permit COC
NCGl00040
Number *
Enter the Certificate of Coverage (OOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Chuck Brown
Obtaining COC*
First and LastNarre
Phone Number* 562-324-7586
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (Optional) Enter an additional errail address to whom to send the OOC
Please review the information below for accuracy before submitting. If there are inconsistencies, please
contact Bethany Georgoulias at [phone] or [e-mail].
Master General NCGl00000
Permit No.
COC No.
NCG100040
Permittee
Lkq Southeast Inc
Facility Name
LKQ Salisbury
Address
3720 Burlington Rd
City
Greensboro
County
Guilford
Waterbody
South Buffalo Creek
Classification
WS-V;NSW
River Basin
Cape Fear
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 * 12/07/2018