NCG030240_Renewal COC Request_20181130 4:42:16 PM

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NORTH CAFOLINA
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Permit COC
NCG030240
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
Jonathan Chase
Obtaining COC*
First and LastNarre
Phone Number* 336-423-5552
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.
NCG030240
Permittee
Deere Hitachi Const Mach Corp
Facility Name
Deere Hitachi Const Mach Corp
Address
1000 Deere -Hitachi Rd
City
Kernersville
County
Forsyth
Waterbody
Kerners Mill Creek
Classification
WS-III
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 /30/2018