NCG160199_Renewal COC Request_20200603 1:43:38 PM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG160199
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Pen-rit nurrber (e.g., N00030222 is the OOC, not
N00030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
Mark Fortner
Obtaining COC*
First and Last Name
Phone Number* 828-488-6298
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. NCG160199
Permittee Hmc Paving & Construction Co Inc
Facility Name HMC Paving
Address 450 Industrial Park Blvd
City Bryson City
County Swain
Waterbody Cochran Branch
Classification C
River Basin Little Tennessee
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.
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 *
vkrlr�
�e * 06/03/2020