NCG070046_Renewal COC Request_20180730 9:36:18 AM

Envirnnmun tat
Quality
Permit COC
NCG070046
Number *
Enter the Certificate of Coverage (COC) number, not the General Rsnit number (e.g., NOG030222 is the OCC, not
NOW30000) MJST BEGIN WTTH CAPRAL "NO3'
Name of Person
Joseph Konzelmann
Obtaining COC*
First and Last Nbrre
Phone Number*
7044382109
Email*
[e-mail]
The COC w ill be e-mailed to this contact.
Additional Email
(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].
M aste r Ge ne ral
NCG070000
Permit No.
COC No.
NCG070046
Permittee
Johnson Concrete Co
Facility Name
Johnson Concrete Inc.
Address
514 Burgin Dr
City
LeAngton
County
Davidson
Waterbody
Michael Branch
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 *
Date * 07/30/2018