NCG130008_Renewal COC Request_20180621 9:58:52 AM

JI
Environmental
Quality
Permit COC
NCG130008
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit number (e.g., NOG030222 is the OOC, not
NOW30000) MUST BEGIN WITH CARTAL "NO3'
Name of Person
Derek Bouchard
Obtaining COC*
First and Last Name
Phone Number*
3143023634
Email *
[e-mail]
The COCwill be e-mailed to this contact.
Additional Email
[e-mail]
(Optional) Enter an additional email address to whom to send the COC
Please review the information below for accuracy before submitting. If there are inconsistencies, please
contact Bethany Georgoulias at [phone] or [e-mail].
Master General
NCG130000
Permit No.
COC No.
NCG130008
Permittee
Republic Services of North Carolina LLC
Facility Name
Winston-Salem Recycling
Address
2876 Lowery St
City
Winston Salem
County
Forsyth
Waterbody
Salem Creek (Middle Fork Muddy Creek,
Salem Lake)
Classification
WS-III;CA
River Basin
Yadkin
RENEWAL STATUS
Active
Issuance Date*
05/31/2018
Effective Date
06/01/2018
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 Storni Permit records.
Signature

Date * 06/21/2018