NCG110021_Renewal COC Request_20180629 9:17:27 AM

Envirnnmun tat
Quality
Permit COC
NCG110021
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit nunber (e.g., NOG030222 is the OCC, not
N00030000) MBT BEGIN WTTH CAPRAL "NO3'
Name of Person
Tonya Mann
Obtaining COC*
First and Last Nbrre
Phone Number*
336 570-6721
Email*
[e-mail]
The COCwill be e-mailed to this contact.
Additional Email
(Optional) Enter an additional email address towhom tosend the OOC
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.
NCG110021
Permittee
City of Graham
Facility Name
Graham WWTP
Address
1204 E Gilbreath St
City
Graham
County
Alamance
Waterbody
Town Branch
Classification
WS-V;NSW
River Basin
Cape Fear
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 *
�OxGr�t2 ai�G
Date * 06/29/2018