NCG050350_COMPLETE FILE - HISTORICAL_20130221

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT N0.
DOC TYPE
E�HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
c%I
YYYYMMDD

of%ArFI p Permit Coverage
Renewal Application Form r
National Pollutant Discharge Elimination System Certificate of Coverage Number
Stormwater General Permit NCGO50000 NCG 050350
Please complete the information in the space provided and return the completed renewal form to the address indicated
below.
Owner Information
Owner / Organization Name
Owner Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Facility Information
Facility Name:
Facility Physical Address:
* Address to which permit correspondence will be mailed
lmaflex, Inc. F_
Joe Abbandonato
5710 Notre Dame West
Montreal, Quebec, Canada - 1-14C 1 V2 j
514-935-5710
514-935-0264
salesnimaflex.com j
Imaflex USA
1200 Unitv Street
Facility Contact:
Daniel Jones
Mailing Address:
Thomaysille,NC 27360
Phone Number:
336-474-1190 ext 31
Fax Number:
336-474-1164
E-mail address:
[e-mail]
Permit Information
Permit Contact:
Daniel Jones
Mailing Address:
1200 Unity Street
Thomasville, NC 27360
Phone Number:
336-474-1190 ext 31
Fax Number:
336-474-1164
E-mail address:
[e-mail]
Discharge Information
Receiving Stream:
Hanks Branch to Hunt's Fork
Stream Class:
Basin:
Yadkin River Basin
Sub -Basin:
Number of Outfalls:
2
Facility/Activity Changes
Please describe below any changes to your facility or
permit. Attached a
separate sheet if necessary.
CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and belief
such information istrue, comol2te and accurate.
Signature X A A'
I D A N i_c L XT. Clj o S
Print or type name of person signing above
Date Z Z/ Z o/ 3
OP-
�_eAT16A)s
Title
SW General Permit Coverage Renewal
Please return this completed application form to: Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617