NCG110157_Renewal COC Request_20181206 4:55:14 PM

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NORTH CAFOLINA
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Permit COC
NCG110157
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
Jim Hollingsworth
Obtaining COC*
First and LastNarra
Phone Number* 3364781202
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
NCG110000
Permit No.
COC No.
NCG110157
Permittee
Shamrock Environmental Corporation
Facility Name
Shamrock Environmental Corporation
Address
6106 Corporate Park Dr
City
Browns Summit
County
Guilford
Waterbody
Unnamed Tributary at Camp Herman (Lake
Herman)
Classification
WS-V,B;NSW
River Basin
Cape Fear
RENEWAL STATUS
Active
Issuance Date*
05/31/2018
Effective Date
06/01/2018
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 * 12/06/2018