NCG080765_Renewal COC Request_20190204 3:44:57 PM

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NORTH CAFOLINA
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Permit COC
NCG080765
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 CAFTTAL "NCG'
Name of Person
Sharon Bass
Obtaining COC*
First and LastNarra
Phone Number* 7044515354
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (Optional) Enter an additional email address to whom to send the CDC
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.
NCG080765
Permittee
Florida Rock & Tank Lines Inc
Facility Name
Florida Rock & Tank Lines - Navassa
Address
1265 Cedar Hill Rd
City
Navassa
County
Brunswick
Waterbody
Cartwheel Branch
Classification
SC;Sw
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 *
uL mr �'W'6';zv 1.
Date * 02/04/2019