NCG180104_Renewal COC Request_20191022 1:57:13 PM

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Permit COC
NCG180104
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
Cory Jackson
Obtaining COC*
First and LastNarra
Phone Number* 276.236.6161
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
NCG180000
Permit No.
COC No.
NCG180104
Permittee
Vaughan -Bassett Furniture Co
Facility Name
Vaughan Bassett Furniture Co
Address
501east Main St
City
Elkin
County
Surry
Waterbody
YADKIN RIVER
Classification
WS-IV
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 * 10/22/2019