NCG060352_Renewal COC Request_20220107 7:41:39 AM

Permit COC Number* NCG060352
Enter the Certificate of Coverage (COC) number. MUST BEGIN WITH CAPITAL "NCG"
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* S&D Coffee Inc
Facility Name S&D Coffee and Tea, Inc.
Address 300 Concord Pkwy S
City Concord
County Cabarrus
Name of Person Jim Barberio
Requesting COC* First and Last Name
Phone Number* 7045170270
Email* [e-mail]
The COC will be e-mailed to this contact.
Additional Email (Optional) Enter an additional email address to whom to send the COC
Master General Permit NCG060000
Issuance Date 06/30/2021
Master General Permit Issuance
Effective Date 07/01 /2021
Master General Permit Effective
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.
I am requesting a copy of the renewal COC.
<< Do not check this box below unless you verified the COC is expired with the report above. >>
the COC is still expired, but owed fees have been paid.
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*
0,&' ced At",
Date * 01 /07/2022
Time 07:41:39 AM
If you do not receive an email with a copy of your renewal COC within a day,
please contact [e-mail]