NCG160025_Renewal COC Request_20191018 5:03:20 PM

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NORTH CAFOLINA
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Permit COC
NCG160025
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 CAFTTAL "NCG'
Name of Person
Joel Greene
Obtaining COC*
First and LastNarra
Phone Number* 336-835-7506
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].
Master General NCG160000
Permit No.
COC No.
NCG160025
Permittee
Carl Rose & Sons Inc
Facility Name
Carl Rose and Sons - Elkin Asphalt #3
Address
155 Asphalt Trl
City
Elkin
County
Surry
Waterbody
YADKIN RIVER
Classification
C
River Basin
Yadkin
RENEWAL STATUS
Active
Issuance Date*
08/01/2019
Effective Date
08/01/2019
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 * 10/18/2019