NCG080716_Renewal COC Request_20181214 9:36:09 AM

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NORTH CAFOLINA
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Permit COC
Number*
Name of Person
Obtaining COC*
Phone Number*
NCG080716
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.
NCG080716
Permittee
Pfj Southeast LLC
Facility Name
PFJ Southeast, LLC
Address
801 NC Hwy 24 E
City
Candor
County
Montgomery
Waterbody
Cabin Creek
Classification
WS-III
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 * 12/14/2018