NCG180072_Renewal COC Request_20200210 9:40:47 AM

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EnHmnmertm! dafny
Permit COC
NCG180072
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
Matt Jenkins
Obtaining COC*
First and Last Narre
Phone Number*
8284289361
Email*
[e-mail]
The COC w ill be e-nailed to this contact.
Additional Email
(Optional) Enter an additional email address towhom tosend the OOC
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.
NCG180072
Permittee
Ethan Allen Operations, Inc.
Facility Name
Ethan Allen Operations, Inc.
Address
700 S Main Ave
City
Maiden
County
Catawba
Waterbody
Shady 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 *
fwal-j"-0�1r,61 �, � I
Date * 02/10/2020