NCG030461_Renewal COC Request_20181130 2:51:05 PM

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NORTH CAFOLINA
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Permit COC
NCG030461
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 CAFTTAL "NCG'
Name of Person
Gregory Smith
Obtaining COC*
First and LastNarra
Phone Number* 704-278-1000
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
NCG030000
Permit No.
COC No.
NCG030461
Permittee
Gem Fabrication of North Carolina Inc
Facility Name
Gem Fabrication of North Carolina Inc
Address
10230 Statesville Blvd
City
Cleveland
County
Rowan
Waterbody
Withrow 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 *
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Date * 11 /30/2018