NCG160195_Renewal COC Request_20191021 2:06:15 PM

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Permit COC
NCG160195
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
Renee Gilbert
Obtaining COC*
First and LastNarra
Phone Number* 3368548200
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 GOC
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.
NCG160195
Permittee
Gemseal
Facility Name
Gem Seal of NC
Address
139 S Walnut Cir
City
Greensboro
County
Guilford
Waterbody
South Buffalo Creek
Classification
WS-V;NSW
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 *
Date * 10/21 /2019