NCG160177_Renewal COC Request_20191021 1:58:45 PM

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Permit COC
NCG160177
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
Ken Olsen
Obtaining COC*
First and LastNarra
Phone Number* 8042640707
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.
NCG160177
Permittee
Asphalt Emulsion Inc
Facility Name
Asphalt Emulsion, Inc.
Address
151 Emmett Rd
City
Dunn
County
Harnett
Waterbody
Black River (Little Black River) (Popes Lake,
Rhodes Pond)
Classification
C;Sw
River Basin
Cape Fear
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 *
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Date * 10/21 /2019