NCG030524_Renewal COC Request_20181203 1:58:50 PM

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NORTH CAFOLINA
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Permit COC
NCG030524
Number *
Enter the Certificate of Coverage (OOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
James Hackney
Obtaining COC*
First and Last Nlarre
Phone Number* 252-406-5921
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.
NCG030524
Permittee
Richard Shirlow/Cooper Interconnect
Facility Name
Cooper Interconnect
Address
4758 E Washington St
City
La Grange
County
Lenoir
Waterbody
Mosely Creek
Classification
C;Sw,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