NCG210267_Renewal COC Request_20180903 2:48:09 PM

Envirnnmun tat
Quality
Permit COC
NCG210267
Number *
Enter the Certificate of Coverage (COC) number, not the General Permit number (e.g., N0G030222 is the OCC, not
N00030000) MBT BEGIN WTTH CAPRAL "NO3'
Name of Person
Randy Miller
Obtaining COC*
First and Last Nbrre
Phone Number*
336-366-2770
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].
M aste r Ge ne ral
NCG210000
Permit No.
COC No.
NCG210267
Permittee
Pine Log Co Inc
Facility Name
Pine Log Co Incorporated
Address
PO Box 858
City
Elkin
County
Surry
Waterbody
Mitchell River
Classification
C
River Basin
Yadkin
RENEWAL STATUS
Active
Issuance Date *
07/31/2018
Effective Date
08/01/2018
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 * 09/03/2018