NCG110062_Renewal COC Request_20180628 11:39:04 AM

JI
Environmental
Quality
Permit COC
NCG110062
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 WITH CARTAL "NO3'
Name of Person
Timothy Robbins
Obtaining COC*
First and Last Narre
Phone Number* [phone]
Email * [e-mail]
The OOCw ill be e-mailed to this contact.
Additional Email (Optional) Enter an additional eneil 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
NCG110000
Permit No.
COC No.
NCG110062
Permittee
Town of Benson
Facility Name
Benson WWTP
Address
770 Hannah Creek Rd
City
Benson
County
Johnston
Waterbody
Hannah Creek
Classification
QNSW
River Basin
Neuse
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 *
%w#� w4v
Date * 06/28/2018