NCG080801_Renewal COC Request_20181227 7:32:22 AM

'rl n
NORTH CAFOLINA
Emlre -.1 Qd Wy
Permit COC
NCG080801
Number *
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Donnie McDaniel
Obtaining COC*
First and LastNarre
Phone Number* 336-748-3893
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 GOC
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.
NCG080801
Permittee
Winston-Salem/Forsyth County Utilities
Commission
Facility Name
Fleet Services Department -Building #3
Address
650 Stadium Dr
City
Winston Salem
County
Forsyth
Waterbody
Salem Creek (Middle Fork Muddy Creek)
Classification
C
River Basin
Yadkin
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 * 12/27/2018