NCG210390_Renewal COC Request_20190215 9:14:20 AM

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Permit COC
NCG210390
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 CAPITAL "NCG'
Name of Person
Dale Elmore
Obtaining COC*
First and LastNarre
Phone Number* 704 445 9610 ext 113
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 NCG210000
Permit No.
COC No.
NCG210390
Permittee
R-Anell Housing Group
Facility Name
R-Anell Housing
Address
235 Anthony Grove Rd
City
Crouse
County
Gaston
Waterbody
Beaverdam Creek
Classification
WS-IV
River Basin
Catawba
RENEWAL STATUS
Active
Issuance Date*
07/31/2018
Effective Date
08/01/2018
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 * 02/15/2019