NCG080695_Renewal COC Request_20210118 8:32:32 AM

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/18/2021 8:32:31 AM (COC Request Submission)

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
NCG080695
Number *
Enter the Certificate of Coverage (COC) nun ber, not the General Permit nurrber (e.g., N00030222 is the OOC, not
NOG030000) M-ST BEGIN WTTH CARTAL "NOG'
Name of Person
Chris Ritchie
Obtaining COC*
First and Last Name
Phone Number* 17047542549
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].
M aste r Ge ne ral NCG080000
Permit No.
COC No.
NCG080695
Permittee
Town of Landis
Facility Name
Landis Public Works Department
Address
704 W Blume St
City
Landis
County
Rowan
Waterbody
Flat Rock Branch (South Branch Grants
Creek) (Lake Corriher)
Classification
WS-IV;CA
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 *
Date * 01 /18/2021