NCG080315_Renewal COC Request_20181213 2:49:19 PM

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NORTH CAFOLINA
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Permit COC
NCG080315
Number *
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAFTTAL "NCG'
Name of Person
Ernie Koury Jr
Obtaining COC*
First and LastNarra
Phone Number* 336-226-5581
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (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].
M aste r Ge ne ral
NCG080000
Permit No.
COC No.
NCG080315
Permittee
Ernie Koury Jr
Facility Name
The Place
Address
1453 Industry Dr
City
Burlington
County
Alamance
Waterbody
Little Alamance Creek (Gant Lake, Mays
Lake) (Alamance County)
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 *
lt 1W41 CAlw C"A'

Date * 12/13/2018