NCG050423_Renewal COC Request_20200709 10:37:43 AM

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Permit COC
NCG050423
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Pernit nurrber (e.g., N00030222 is the ODC, not
N00030000) M-ST BEGIN WTTH CARTAL "NOG'
Name of Person
Randy Ayscue
Obtaining COC*
First and Last Name
Phone Number* 7042234876
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
Did you check the permit COC file in our repository to ensure this COC was not already available from a previous
request? If it is, please obtain it from there instead of this form.
V Yes, this COC was not already there.
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
NCG050000
Permit No.
COC No.
NCG050423
Permittee
Palziv North America
Facility Name
Palziv North America
Address
7966 NC Hwy 56
City
Louisburg
County
Franklin
Waterbody
Wolfpen Branch
Classification
QNSW
River Basin
Tar -Pamlico
RENEWAL STATUS
Active
Issuance Date*
05/31/2018
Effective Date
06/01/2018
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 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 *
1r�..j00rul-
Date * 07/09/2020