NCG060373_Renewal COC Request_20181128 8:56:09 AM

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NORTH CAFOLINA
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Permit COC
NCG060373
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
Tonya Branson
Obtaining COC*
First and LastNarre
Phone Number* 9102841991
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.
NCG060373
Permittee
House of Raeford Farms Inc
Facility Name
House of Raeford - Filet of Chicken
Address
251 Eaton Dr
City
Mocksville
County
Davie
Waterbody
Leonard Creek
Classification
C
River Basin
Yadkin
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