NCG050110_Renewal COC Request_20180702 9:55:25 AM

JI
Environmental
Quality
Permit COC
NCG050110
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit number (e.g., NOG030222 is the OOC, not
Facility Name
NCG030000) MUST BEGIN WITH CARTAL "NO3'
Name of Person
Viktoriya Khvorostovska
Obtaining COC*
First and Last Narre
Phone Number* 336-777-5878
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.
NCG050110
Permittee
Oracle Flexible Packaging Inc
Facility Name
Plant 604 / Polo Road Complex
Address
220 E Polo Rd
City
Winston Salem
County
Forsyth
Waterbody
Silas Creek
Classification
C
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 *
Vkio, ZW-moslcht &
Date * 07/02/2018