NCG100170_Renewal COC Request_20181204 10:05:26 AM

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Permit COC
NCG100170
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 "NOG'
Name of Person
kathy nelson
Obtaining COC*
First and LastNarra
Phone Number* 3365786977
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].
Master General NCG100000
Permit No.
COC No.
NCG100170
Permittee
Crutchfield's Auto Parts LLC
Facility Name
Crutchfield's Auto Parts, LLC
Address
1639 Hwy 70
City
Mebane
County
Alamance
Waterbody
Back Creek
Classification
WS-V;NSW
River Basin
Cape Fear
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 * 12/04/2018