NCG170242_Renewal COC Request_20191022 1:17:24 PM

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NORTH CAFOLINA
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Permit COC
NCG170242
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 CAFTTAL "NCG'
Name of Person
Keara Hinge
Obtaining COC*
First and LastNarra
Phone Number* 9194848536
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 CDC
Please review the information below for accuracy before submitting. If there are inconsistencies, please
contact Bethany Georgoulias at [phone] or [e-mail].
Master General
NCG170000
Permit No.
COC No.
NCG170242
Permittee
Shawmut Park Avenue LLC
Facility Name
Shawmut Park Avenue, LLC
Address
1821 N Park Ave
City
Burlington
County
Alamance
Waterbody
Service Creek (Servis 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 *
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Date * 10/22/2019