NCG060104_Renewal COC Request_20181126 5:35:47 PM

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NORTH CAFOLINA
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Permit COC
NCG060104
Number *
Enter the Certificate of Coverage (COC) number, not the General Fbrmt number (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Kay Jacobs
Obtaining COC*
First and LastNarre
Phone Number* 3368620032
Email * [e-mail]
The COC will be e-rrailed 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].
M aste r Ge ne ral NCG060000
Permit No.
COC No.
NCG060104
Permittee
Alberdingk Boley Inc
Facility Name
Alberdingk Boley Inc
Address
6008 High Point Rd
City
Greensboro
County
Guilford
Waterbody
Bull Run
Classification
WS-IV:'
River Basin
Cape Fear
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