NCG060105_Renewal COC Request_20181203 10:37:02 AM

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Permit COC
NCG060105
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
David Schaefer
Obtaining COC*
First and Last Nlarre
Phone Number* 919-269-5000
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.
NCG060105
Permittee
Glaxosmithkline
Facility Name
Glaxosmithkline - Zebulon
Address
1011 N Arendell Ave
City
Zebulon
County
Wake
Waterbody
Little River (Tarpleys Pond)
Classification
WS-V;NSW
River Basin
Neuse
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 * 12/03/2018