NCG030025_Renewal COC Request_20181128 8:29:37 AM

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NORTH CAFOLINA
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Permit COC
NCG030025
Number *
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WITH CAPITAL "NCG'
Name of Person
JOSEPH PEACOS III
Obtaining COC*
First and LastNarre
Phone Number* 2526447154
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].
M aste r Ge ne ral
NCG030000
Permit No.
COC No.
NCG030025
Permittee
Vt Hackney Division
Facility Name
VT - Hackney Division
Address
400 Hackney Ave
City
Washington
County
Beaufort
Waterbody
TAR RIVER
Classification
QNSW
River Basin
Tar -Pamlico
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 /28/2018