NCG160214_Renewal COC Request_20191025 1:14:14 PM

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NORTH CAFOLINA
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Permit COC
NCG160214
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
Alisa Hatmaker
Obtaining COC*
First and LastNarre
Phone Number* 865-333-0689
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.
NCG160214
Permittee
Ralph Rogers and Company
Facility Name
Ralph Rogers and Company - Henrietta
Asphalt
Address
1385 Ferry Rd
City
Mooresboro
County
Rutherford
Waterbody
Hog Pen Branch
Classification
WS-IV
River Basin
Broad
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 * 10/25/2019