NCG100224_Renewal COC Request_20181126 11:35:23 AM

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Permit COC
NCGl00224
Number *
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Ronald Church
Obtaining COC*
First and LastNarra
Phone Number* 7044823911
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (Optional) Enter an additional email address to whom to send the CDC
Please review the information below for accuracy before submitting. If there are inconsistencies, please
contact Bethany Georgoulias at [phone] or [e-mail].
Master General
NCGl00000
Permit No.
COC No.
NCGl00224
Permittee
Church Auto Parts Inc
Facility Name
Church Auto Parts Inc
Address
1839 Lowman Rd
City
Shelby
County
Cleveland
Waterbody
Buffalo Creek (Kings Mountain Reservoir)
Classification
WS-III;CA
River Basin
Broad
RENEWAL STATUS
Active
Issuance Date*
10/29/2018
Effective Date
11/01/2018
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 * 11 /26/2018