NCG080778_Renewal COC Request_20200527 5:16:36 PM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG080778
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General P n-rit nurrber (e.g., N00030222 is the OOC, not
NCG030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
Taylor Scarborough
Obtaining COC*
First and Last Name
Phone Number* 4787437175
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].
M aste r Ge ne ral NCG080000
Permit No.
COC No. NCGO80778
Permittee Republic Services of North Carolina LLC
Facility Name Republic Services of NC, LLC-GDS-
Cleveland
Address 1160 Airport Rd
City
Shelby
County
Cleveland
Waterbody
Hickory Creek
Classification
C
River Basin Broad
RENEWAL STATUS Active
Issuance Date * 10/29/2018
Effective Date 11/01/2018
I 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 NC 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 NC General Statutes (the "Uniform Electronic Transactions Act");

Signature *
�e * 05/27/2020