NCG180100_Renewal COC Request_20191028 12:23:10 PM

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Permit COC
NCG180100
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
Ethan Allen
Obtaining COC*
First and LastNarre
Phone Number* 8286687686
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 NCG180000
Permit No.
COC No.
NCG180100
Permittee
Ethan Allen Inc - Pine Valley Div
Facility Name
Ethan Allen Inc. - Pine Valley Div.
Address
912 E Main St
City
Old Fort
County
McDowell
Waterbody
Burgen Creek (Butch Branch)
Classification
C
River Basin
Catawba
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
Ack,21 0 %ee(e

Date * 10/28/2019