NCG210295_COMPLETE FILE - HISTORICAL_20130211

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE
R HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑
YYYYM M D D

-R
4 µA?4" Permit Coverage
Renewal Application Form
Y National Pollutant Discharge Elimination System Certificate of Coverage Number
Stormwater General Permit NCG210000 NCG210295
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:
Facilit►► Information
Facility Name:
Facility Physical Address:
Facility Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Permit Information
Permit Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Discharge Informatiion
Receiving Stream:
Stream Class:
Basin:
Sub -Basin:
Number of Outfalls:
* Address to which permit correspondence will be marled
Ronnie D Bolt / Wilderness NC, Inc
Ronnie D Bolt
PO Box 2136,
Lexington, NC 27293
336-474-2314
336-474-6687
[e-mail]
Wilderness NC, Inc.
7578 US Highway 64 E
Thomasville, NC 27360
Shannon Floyd
PO Box 2136
Lexington, NC 27293
336-474-2314
336-474-6687
[e-mail]
Shannon Flog
PO Box 2136
NC 27293
336-474-2314
336-474-6687
[e-mail]
Flat Swamo Creek
C
Yadkin -Pee Dee River
03-07-04 of Yadkin -Pee Dee River Basin
2
kP=@[2"5W1A1
FEB 1 1 2013
o NR - WA -TER ouALiTY
WaUnds & SWMmatw Branch
Facili Activi Chan es Please describe below any changes to your facility or activities since issuance of your 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 is true, complete and accurate.
Signatur(
Print or type name of person signing above
Date 13
C)
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

renIHL wverdye
a9 Renewal Application Form
Y National Pollutant Discharge Elimination System Certificate of Coverage Number
11
Stormwater General. Permit CGZIDDDQ ; NCG210295 .
Please complete the information in the space provided and return the completed'�renewal form to the address indicated
below.
Owner Information * Address to which permit correspondence will be malled
Owner / Organization Name: Ronnie D Bolt / Wilderness NC, Inc _
Owner Contact: Ronnie D Bolt
Mailing Address: PO Box 2136, -_
Lexington, NC 27293
Phone Number: 336-474-2314
Fax Number: 336-474-6687
E-mail address: wdsncPnorthstate. net
Facilitv Information
Facility Name:
Wilderness NC Inc.
Facility Physical Address:
7578 US Highway 64 E
Thomasville, NC 27360
Facility Contact:
Shannon Floyd
Mailing Address:
PO Box 2136
Lexington, NC 27293
Phone Number:
336-474-2314
Fax Number:
.336-474-6687
E-mail address:
[e-mail]
Permit Information
Permit Contact:
_ Shannon Floyd
Mailing Address:
PO Box 2136
Lexington, NC 27293
Phone Number:
336-474-2314
Fax Number:
336-474-6687
E-mail address:
[e-mail]
Discharge Information
Receiving Stream: Fiat Swamp Creek
Stream Class: C
Basin: Yadkin -Pee Dee River
Sub -Basin: 03-07-04 of Yadkin -Pee Dee River Basin
Number of Outfalls: 2
Facility/Activity Changes Please describe below any changes to your facility or activities since issuance of your 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 is true, complete and accurate.
Signature
Print or type name of person signing above
Date Q ` / `
Title
Please return this completed application form to: SW General Permit:Coverage Renewal
p pp Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617