NCG030530_Renewal COC Request_20200903 10:05:41 AM

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG030530
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Pen-rit nurrber (e.g., N00030222 is the ODC, not
NCG030000) M-ST BEGIN WTTH CARTAL "NCG'
Name of Person
Michael Carter
Obtaining COC*
First and Last Name
Phone Number* 828-837-2117
Email * [e-mail]
The CDC w ill be e-nailed to this contact.
Additional Email (Optional) Enter an additional enailaddress towhom tosend 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.
rJ 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 NCG030000
Permit No.
COC No.
NCG030530
Permittee
Indian Head Industries Inc
Facility Name
MGM Brakes
Address
229 Park Ave
City
Murphy
County
Cherokee
Waterbody
HIWASSEE RIVER (Hiwassee Lake below
elevation 1525)
Classification
C
River Basin
Hiwassee
RENEWAL STATUS
Active
Issuance Date*
10/29/2018
Effective Date
11/01/2018
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 * 09/03/2020