NCG130067_Renewal COC Request_20200812 9:55:31 AM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG130067
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Penrit nurrber (e.g., N00030222 is the OOC, not
N00030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
Darrell Pyrtle
Obtaining COC*
First and Last Name
Phone Number* 3366727867
Email * [e-mail]
The COC w ill be e-nailed to this contact.
Additional Email [e-mail]
(Optional) Enter an additional errail 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].
Master General
NCG130000
Permit No.
COC No.
NCG130067
Permittee
Blue Ridge Plastics
Facility Name
Blue Ridge Plastics
Address
11511 May 770 E
City
Eden
County
Rockingham
Waterbody
Dry Creek
Classification
C
River Basin
Roanoke
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 *
Date * 08/12/2020