NCG080134_Renewal COC Request_20181214 9:35:26 AM

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NORTH CAFOLINA
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Permit COC
Number*
Name of Person
Obtaining COC*
Phone Number*
NCG080134
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nunber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Robert Wagner
First and Last Narre
540-563-4920
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (Optional) Enter an additional errail 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 NCG080000
Permit No.
COC No.
NCG080134
Permittee
Pilot Travel Centers LLC
Facility Name
Pilot Travel Centers LLC #68
Address
Rt 1 Box 202
City
Pleasant Hill
County
Northampton
Waterbody
Jacks Swamp
Classification
QNSW
River Basin
Chowan
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 * 12/14/2018