NCG170197_Renewal COC Request_20210414 4:21:19 PM

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/14/2021 4:21:19 PM (COC Request Submission)

NORTH C W Q-rA
EnHmnmertm! dafny
Permit COC
Number*
Name of Person
Obtaining COC*
Phone Number*
NCG170197
Enter the Certificate of Coverage (COC) nun ber, not the General Rarnit nurrber (e.g., NOG030222 is the COC, not
N00030000) M-ST BEGIN WTTH CARTAL "NCG'
Mike Garlick
First and Last Nacre
3363792941
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
NCG170000
Permit No.
COC No.
NCG170197
Permittee
Burlington Industries LLC
Facility Name
Richmond Plant
Address
740 Old Cheraw Hwy
City
Cordova
County
Richmond
Waterbody
Hitchcock Creek (Roberdel Lake)
Classification
WS-III;CA
River Basin
Yadkin
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 *
Z*4
Date * 04/14/2021