SW3190506_Supplemental Info Upload_20191015

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/15/2019 1:05:32 PM (Supplemental Submittal)
Submit by Strickland, Shane 10/16/2019 10:51:37 AM (Supplemental Info Submittal)
• The task was assigned to Strickland, Shane 10/15/2019 1:05 PM

Submittal Dated: 10/15/2019
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Existing Project Information:
Rease supply the permit number for this project.
D# * Flerrrit Number
SW3190506
Exarrples: SWxxxxxxx, NOC;axxxx, or NCSxxxxxx
Facility Name:* Sealand Office
County:
Name: Who is subrritting the information?
Email Address:* [e-mail]
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
2019-09-27 EZ .pdf 1.3MB
Only pdf files are accepted.
Please alert us to any confidential information contained in the uploaded documents.
Uploads contain r NO
Confidential r YES
Information * NOTE The following information cannot be claimed as confidential: the nacre and address of any perrrit applicant or
perrrittee, permit applications, permts, effluent data, information required by 1\11:16S application forms provided by
the Director inclusive of all forms and attachments [Plef. 40 CFR 122.7(b) and (c)].
Describe the attachments:
Supplement-EZ
* V By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
o I agree that submission of this Supplemental Information form is a "transaction" subject to Chapter 66, Article 40 of the
NC General Statutes (the "Uniform Electronic Transactions Act)
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Supplemental Information form."

Full Name:* Frank Cantrell
Signature:
Date Submitted: 10/15/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW3190506
Who needs a d Central Office
copy?* r- Regional Office
Central Office Reviewer:*
Jim Farkas - eads\jjfarkas
Select Reviewing Office*
Mooresville Regional Office — 704-663-1699
Select RO Reviewer:*
[e-mail]