NCG170422_Renewal COC Request_20191025 9:39:15 AM

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Permit COC
NCG170422
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
Dale Kelly
Obtaining COC*
First and LastNarra
Phone Number* 704-848-4121
Email * [e-mail]
The COCw ill 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
NCG170000
Permit No.
COC No.
NCG170422
Permittee
Hornwood Inc
Facility Name
Hornwood, Inc.
Address
766 Haileys Ferry Rd
City
Lilesville
County
Anson
Waterbody
Hale Creek
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 * 10/25/2019