NCG100112_Renewal COC Request_20181130 2:58:28 PM

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NORTH CAFOLINA
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Permit COC
NCG100112
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
Wiliam Dougherty
Obtaining COC*
First and LastNarre
Phone Number* 434-489-1597
Email* [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (Optional) Enter an additional errail 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.
NCG100112
Permittee
P and D Automotive Systems
Facility Name
P and D Automotive Systems
Address
194 Red Marshall Rd
City
Pelham
County
Caswell
Waterbody
Tardy Branch
Classification
C
River Basin
Roanoke
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