NCG210238_Renewal COC Request_20180910 9:32:00 AM

Environmental
Quality
Permit COC
NCG210238
Number *
Enter the Certificate of Coverage (COC) number, not the General Pernit number (e.g., NOG030222 is the OOC, not
NCG030000) MUST BEGIN WTTH CARTAL "NO3'
Name of Person
Brian Dyson
Obtaining COC*
First and Last Name
Phone Number*
336-492-5565
Email *
[e-mail]
The OOCw ill be e-mailed to this contact.
Additional Email
[e-mail]
(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].
Master General
NCG210000
Permit No.
COC No.
NCG210238
Permittee
Palletone of NC Inc
Facility Name
Pallet One Butner
Address
10 26th St
City
Butner
County
Granville
Waterbody
Picture Creek
Classification
WS-IV;NSW
River Basin
Neuse
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 *
ff'ta
Date * 09/10/2018