NCG030672_Renewal COC Request_20200519 1:38:16 PM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG030672
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Pen-rit nurrber (e.g., N00030222 is the ODC, not
NCG030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
Katelyn Kellam
Obtaining COC*
First and Last Name
Phone Number* 910 428 2368
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].
M aste r Ge ne ral NCG030000
Permit No.
COC No. NCG030672
Permittee K-M Machine Company
Facility Name K-M Machine Company, Inc.
Address 275 Sedberry Rd
City Biscoe
County Montgomery
Waterbody Hickory Branch
Classification C
River Basin Yadkin
RENEWAL STATUS Active
Issuance Date* 10/29/2018
Effective Date 11/01/2018
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.
In addition, I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the INC General
Statutes (the "Uniform Electronic Transactions Act"); and I agree to conduct this transaction by electronic means
pursuant to Chapter 66, Article 40 of the INC General Statutes (the "Uniform Electronic Transactions Act");

Signature *
�e * 05/19/2020