NCG160223_Renewal COC Request_20220307 12:40:26 PM

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 3/7/2022 12:40:25 PM (COC Request Submission)

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Permit COC Number* NCG160223
Enter the Certificate of Coverage (COC) number, not the General Permit number (e.g., NCG030222 is the COC,
not NCG030000) MUST BEGIN WITH CAPITAL "NCG"
Name of Person Kenny Caviness via DEQ Staff Request (B.
Obtaining COC* Georgoulias)
First and Last Name
Phone Number* [phone]
Email* [e-mail]
The COC will be e-mailed to this contact.
Additional Email [e-mail]
(Optional) Enter an additional email address to whom to send the COC
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.
* 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
NCG160000
Permit No.
COC No.
NCG160223
Permittee
Fibercrete Preservation Technologies Inc
Facility Name
Fibercrete Preservation Technologies, Inc.
Address
301 Old Hwy 52 S
City
Mount Airy
County
Surry
Waterbody
Stoney Creek
Classification
C
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*
Date * 03/07/2022