NCG080707_Renewal COC Request_20190102 2:27:57 PM

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Permit COC
NCG080707
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 CAFTTAL "NCG'
Name of Person
Bryan Duckworth
Obtaining COC*
First and LastNarre
Phone Number* 8284438447
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].
M aste r Ge ne ral
NCG080000
Permit No.
COC No.
NCG080707
Permittee
Town of Valdese
Facility Name
Valdese Public Works
Address
100 Whisnant St
City
Valdese
County
Burke
Waterbody
Micol Creek
Classification
WS-IV
River Basin
Catawba
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 * 01 /02/2019