NCG060352_Renewal COC Request_20201118 1:45:31 PM

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/18/2020 1:45:30 PM (COC Request Submission)

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG060352
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
Jim Barberio
Obtaining COC*
First and Last Name
Phone Number* 7045170270
Email * [e-mail]
The COC 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
NCG060000
Permit No.
COC No.
NCG060352
Permittee
S&D Coffee Inc
Facility Name
S&D Coffee and Tea, Inc.
Address
300 Concord Pkwy S
City
Concord
County
Cabarrus
Waterbody
Irish Buffalo Creek
Classification
C
River Basin
Yadkin
RENEWAL STATUS
Active
Issuance Date*
10/29/2018
Effective Date
11/01/2018
Effective Date
20181101
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 *
CZ1 lofllfwee
Date * 11 /18/2020