NCG050277_Renewal COC Request_20180628 9:50:33 AM

JI
Environmental
Quality
Permit COC
NCG050277
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit number (e.g., NOG030222 is the OOC, not
COC No.
NCG030000) MUST BEGIN WTTH CARTAL "NO3'
Name of Person
David Barlow
Obtaining COC*
First and Last Name
Phone Number* 336-778-6034
Email * [e-mail]
The COCwill be e-mailed to this contact.
Additional Email (Optional) Enter an additional enail 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].
M aste r Ge ne ral
NCG050000
Permit No.
COC No.
NCG050277
Permittee
Hayward Industries Inc
Facility Name
Hayward Industries Incorporated
Address
One Hayward Industrial Dr
City
Clemmons
County
Forsyth
Waterbody
Johnson Creek
Classification
WS -IV
River Basin
Yadkin
RENEWAL STATUS
Active
Issuance Date*
05/31/2018
Effective Date
06/01/2018
1 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.
Signature *
Pi wr x
Date * 06/28/2018