NCG050348_Renewal COC Request_20190813 10:32:27 AM

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NORTH CAFOLINA
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Permit COC
NCG050348
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
Jimmy Petry
Obtaining COC*
First and LastNarra
Phone Number* 7048784452
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
NCG050000
Permit No.
COC No.
NCG050348
Permittee
Mack Molding Company
Facility Name
Mack Molding Company
Address
149 Water Tank Rd
City
Statesville
County
Iredell
Waterbody
Broad Meadow Creek
Classification
WS-IV
River Basin
Catawba
RENEWAL STATUS
Active
issuance Date*
05/31/2018
Effective Date
06/01/2018
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 * rr/-
GIl &41/fir f51 c7.

Date * 08/13/2019