NCG160102_Renewal COC Request_20201019 3:24:57 PM

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/19/2020 3:24:57 PM (COC Request Submission)

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Permit COC
NCG160102
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Perrrit nurrber (e.g., N00030222 is the OOC, not
N00030000) M-ST BEGIN WTTH CARTAL "NOG'
Name of Person
John T Perry
Obtaining COC*
First and Last Name
Phone Number* 12522877829
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
NCG160000
Permit No.
COC No.
NCG160102
Permittee
Rose Brothers Paving Co Inc
Facility Name
Rose Brothers Paving -Hertford
Address
Sr 1224 At US 17
City
Hertford
County
Perquimans
Waterbody
Little River
Classification
C;Sw
River Basin
Pasquotank
RENEWAL STATUS
Active
Issuance Date*
08/01/2019
Effective Date
08/01/2019
Effective Date
20190801
Reformatted
I 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 *
C,&,V0�,�
Date * 10/19/2020