NCG110103_Renewal COC Request_20190327 3:37:19 PM

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NORTH CAFOLINA
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Permit COC
Number*
Name of Person
Obtaining COC*
Phone Number*
NCG110103
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'
Sonny Penson
First and Last Narre
8282485217
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].
Master General NCG110000
Permit No.
COC No.
NCG110103
Permittee
Town of Forest City
Facility Name
Forest City WWTP
Address
397 Riverside Dr
City
Forest City
County
Rutherford
Waterbody
Second Broad River
Classification
WS-IV
River Basin
Broad
RENEWAL STATUS
Active
Issuance Date*
05/31/2018
Effective Date
06/01/2018
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 *
11- OM'� C�'c

Date * 03/27/2019