NCG210295_Renewal COC Request_20180905 8:32:42 AM

JI
Environmental
Quality
Permit COC
NCG210295
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit number (e.g., NOG030222 is the OOC, not
COC No.
NOW30000) MUST BEGIN WTTH CARTAL "NO3'
Name of Person
BELINDA MILAN
Obtaining COC*
First and Last Narre
Phone Number* 336-474-2314
Email * [e-mail]
The OOCw ill be e -n -ailed 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].
M aste r Ge ne ral
NCG210000
Permit No.
COC No.
NCG210295
Permittee
Wilderness N C Inc
Facility Name
Wilderness INC, Inc.
Address
7578 US 64 E
City
Thomasville
County
Davidson
Waterbody
Flat Swamp Creek
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 * 09/05/2018