NCG550097_Renewal (Application)_20220209

PAT MCCRORY
Gore;;,nr
DONALD R. VAN DER VAART
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Di/trio/
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG55 O©9'7
(Please verify the information in items 1 & 2 as correct, or note any corrections that should be made.)
(Please print or type)
1) Mailing address*of property owner: \� ,�,`
Owner Name YO�r\C-\ \� S:r
O� (o V --0 Yl ;co, o rd v-�`N1 kee rf1C A•co r eyay Qp\
Street Address 1\'Aq d
City x- ,(3\1
\\lS1 NC 0.1SL\
Telephone (Home) (Mobile) WA LI33 J—I
(e-mail address) jklirra� 7 m3\@ pme LC w1 _
*Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*: RECEIVED
Street Address F€.$ 0 9 2022
City:
NCDEQ/gWR/NPDES
County
Telephone (Home)_ (Mobile)
* If the facility is not yet constructed, give the street address or lot number where the structure will be
built.
3) Description of Discharge:
a) Type of facility producing waste (please check one):
LX Primary residence
❑ Vacation/second home
❑ Undeveloped property
❑ Other [describe]:
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