NCG180177_Renewal COC Request_20190912 2:08:40 PM

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NORTH CAFOLINA
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Permit COC
Number*
Name of Person
Obtaining COC*
Phone Number*
Email *
Additional Email
NCG180177
Enter the Certificate of Coverage (GOC) number, not the General Fbrmt nunber (e.g., NCGO30222 is the COC, not
NCG030000) M-ST BEGIN WTTH CAFTTAL "NCG'
Chris Farabee
First and Last Narre
828-679-2615
[e-mail]
The GOCwill be e-rrailed to this contact.
(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
Permit No.
COC No.
Pe rmitte e
Facility Name
Address
City
County
Wate rbody
Classification
River Basin
RENEWAL STATUS
Issuance Date*
Effective Date
I 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 *
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Date * 09/12/2019