NCG180194_Renewal COC Request_20191031 4:32:53 PM

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NORTH CAFOLINA
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Permit COC
NCG180194
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
Michael L Thompson
Obtaining COC*
First and LastNarre
Phone Number* 3369633891
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.
NCG180194
Permittee
Klaussner Furniture Ind Inc
Facility Name
Klaussner Furniture -PI 1 5 6 7
Address
405 Lewallen St
City
Asheboro
County
Randolph
Waterbody
Unnamed Tributary to Cedar Fork Creek
Classification
WS-II;HQW
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 * 10/31 /2019