NCG160221_Renewal COC Request_20191227 1:08:22 PM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG160221
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Pen-rit nurrber (e.g., N00030222 is the OOC, not
NCG030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
JAMES WILLARD II
Obtaining COC*
First and Last Name
Phone Number* 7046628192
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.
NCG160221
Permittee
Blythe Brothers Asphalt Company L L C
Facility Name
Blythe Brothers Asphalt Company, LLC
Address
10447 Old Nations Ford Rd
City
Charlotte
County
Mecklenburg
Waterbody
Kings 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 *
1-1� '�rwW—e `

Date * 12/27/2019