NCG060186_Renewal COC Request_20210802 3:23:45 PM

Permit COC NCG060186
Number * Enter the Certificate of Coverage (COC) nun ber. MIST BEGIN WITH C4RTAL "NOG'
Please review the information below for accuracy before submitting. If there are inconsistencies, please contact
[e-mail], or check the box below that says "permit information is incorrect".
Permittee * Wayne Farms LLC
Facility Name Elkin Feed Mill
Address Rt 3 Box 384
City Elkin
County Surry
Name of Person Jonathan Green
Requesting COC* First and LastNarre
Phone Number* [phone]
Email * [e-mail]
The COC w ill be e-nailed to this contact.
Additional Email [e-mail]
(Optional) Enter an additional email address to whom to send the ODC
M aste r Ge ne ral Pe rmit NCG060000
Issuance Date 06/30/2021
Master General Flarmit Issuance
Effective Date 07/01/2021
Master General Permit fffective
NOTE: You can verify the COC facility information and renewal status by running this Permit Summary Report (check the
effective and expiration dates at the top of the report). If the permit is expired, a renewal COC will not be
available. This may be because fees are owed. You can check for outstanding invoices at https://deq.nc.gov/sw-
epayments.
r- owed fees have been paid, but the COC is still expired.
r permit information is incorrect or old.
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. If a COC is not available, I request a
follow-up from Stormwater Program staff.
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 *
,, 0A141VA- d ��f

Date * 08/02/2021
Time 03:23:45 PM
If you do not receive an email with a copy of your renewal COC within a day, please contact
[e-mail] or [e-mail]