NCG110030_Renewal COC Request_20200715 10:22:11 AM

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Permit COC
Number*
Name of Person
Obtaining COC*
Phone Number*
NCG 110030
Enter the Certificate of Coverage (COC) nun ber, not the General Parnit nurrber (e.g., NOG030222 is the OOC, not
N00030000) M-ST BEGIN WTTH CARTAL "NCG'
Amanda James
First and Last Nacre
2529721405
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 OOC
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].
Master General
NCG110000
Permit No.
COC No.
NCG110030
Permittee
City of Rocky Mount
Facility Name
Tar River Regional WWTP
Address
3031 Water Treatment Plant Rd
City
Rocky Mount
County
Edgecombe
Waterbody
TAR RIVER
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 *
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Date * 07/15/2020