NCG030531_Renewal COC Request_20190510 8:56:42 AM

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NORTH CAFOLINA
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Permit COC
NCG030531
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 CAPITAL "NCG'
Name of Person
Michael Keen
Obtaining COC*
First and LastNarre
Phone Number* 9802370373
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 NCG030000
Permit No.
COC No.
NCG030531
Permittee
Kings Mountain International, Inc.
Facility Name
Kings Mountain International, Inc.
Address
1755 S Battleground Ave
City
Kings Mountain
County
Cleveland
Waterbody
Dixon Branch
Classification
C
River Basin
Broad
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 * 05/10/2019