NCG120088_Renewal COC Request_20190430 12:31:04 PM

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NORTH CAFOLINA
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Permit COC
NCG120088
Number *
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NOG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Mike Gurley
Obtaining COC*
First and LastNarra
Phone Number* 704-262-6019
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].
Master General NCG120000
Permit No.
COC No.
NCG120088
Permittee
Republic Services Inc
Facility Name
Lake Norman C & D
Address
7099 Quarry Ln
City
Stanley
County
Lincoln
Waterbody
Forney Creek
Classification
C
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 *
r ie�Y
Date * 04/30/2019