NCG080813_Renewal COC Request_20210809 9:45:07 AM

Permit COC NCGO80813
Number * Enter the Certificate of Coverage (COC) number. 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 * Associated Asphalt Winston-Salem LLC
Facility Name Associated Asphalt Winston-Salem, LLC
Address 5025 Overdale Rd
City Winston Salem
County Forsyth
Name of Person David Thomson
Requesting COC* First and Last Nbme
Phone Number* 5407977356
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 NCGO80000
Issuance Date 06/30/2021
Master General Fbmit Issuance
Effective Date 07/01/2021
Mister General Permit fffective
NOTE: You can verify the COC facility information and renewal status by running this Permit Summary Report (check the
Permit Status 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.
«Before checking this box, please verifythe COC is expired with the report above. »
r- the COC is still expired, but owed fees have been paid.
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
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Date * 08/09/2021
Time 09:45:07 AM
If you do not receive an email with a copy of your renewal COC within a day, please contact
[e-mail] or [e-mail]