NCG120056_Renewal COC Request_20181221 10:00:26 AM

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NORTH CAFOLINA
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Permit COC
NCG120056
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 CAPITAL "NCG'
Name of Person
Matt Einsmann
Obtaining COC*
First and LastNarre
Phone Number* 9193543227
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].
Master General NCG120000
Permit No.
COC No.
NCG120056
Permittee
Republic Services of North Carolina LLC
Facility Name
Upper Piedmont Evironmental Landfill
Address
US Hwy No 158
City
Roxboro
County
Person
Waterbody
Cub Creek and Rock Fork Branch
Classification
WS-IV;NSW and WS-III;ORW,NSW
River Basin
Tar -Pamlico and 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 *
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Date * 12/21 /2018