NCG080813_Renewal COC Request_20181218 10:11:24 AM

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Permit COC
NCG080813
Number *
Enter the Certificate of Coverage (COC) number, not the General Fbrmt number (e.g., NCGO30222 is the COC, not
NOG030000) M-ST BEGIN WTTH CAFTTAL "NCG'
Name of Person
Andrew Hetz
Obtaining COC*
First and LastNarra
Phone Number* 5405992594
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 NCG080000
Permit No.
COC No.
NCG080813
Permittee
Associated Asphalt Winston-Salem LLC
Facility Name
Associated Asphalt Winston-Salem, LLC
Address
5025 Overdale Rd
City
Winston Salem
County
Forsyth
Waterbody
South Fork Muddy Creek
Classification
C
River Basin
Yadkin
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 * 12/18/2018