NCG060348_Renewal COC Request_20190102 12:35:50 PM

'rl n
NORTH CAFOLINA
Emlre -.1 Qd Wy
Permit COC
NCG060348
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 CAPITAL "NCG'
Name of Person
Kelley Brown
Obtaining COC*
First and LastNarra
Phone Number* 910-259-2232
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
NCG060000
Permit No.
COC No.
NCG060348
Permittee
American Skin Co
Facility Name
American Skin Food Group LLC
Address
140 Industrial Dr
City
Burgaw
County
Pender
Waterbody
Burgaw Creek
Classification
C;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 *
� "Xw
Date * 01 /02/2019