NCG180036_Renewal COC Request_20191029 12:04:22 PM

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NORTH CAFOLINA
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Permit COC
NCG180036
Number *
Enter the Certificate of Coverage (OOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
James Kozminski
Obtaining COC*
First and LastNarra
Phone Number* 616-393-1533
Email * [e-mail]
The OOCw ill 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.
NCG180036
Permittee
Haworth Inc
Facility Name
Haworth Inc -Wood Seating Plant
Address
1673 English Rd
City
High Point
County
Guilford
Waterbody
Payne 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 * 10/29/2019