NCG160219_Renewal COC Request_20191125 2:33:39 PM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG160219
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Pen-rit nurrber (e.g., N00030222 is the OOC, not
N00030000) M-ST BEGIN WTTH CARTAL "NOG'
Name of Person
patrick tucker
Obtaining COC*
First and Last Name
Phone Number* 336-765-7900
Email * [e-mail]
The COC w ill be e-nailed to this contact.
Additional Email [e-mail]
(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 NCG160000
Permit No.
COC No.
NCG160219
Permittee
Yadkin Valley Paving Inc
Facility Name
Yadkin Valley Paving Inc
Address
121 Cloverleaf Dr
City
Winston Salem
County
Forsyth
Waterbody
Salem Creek (Middle Fork Muddy 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 *
M r-w

Date * 11 /25/2019