NCG020793_Supplemental Info Review (DMR)_20211028

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/28/2021 11:16:28 AM (Supplemental Submittal)
Submit by Georgoulias, Bethany A 1/5/2022 5:00:53 PM (Supplemental Info Submittal)
IN COC number was on uploaded DMR (NCG020793)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 1/4/2022 8:27 PM
• The task was assigned to McCoy, Suzanne 10/28/2021 11:16 AM

Submittal from 10/28/2021
Permit Information:
Please provide specific hermit details below.
What Type of Permit? Choose one:
* NPDES Industrial or MS4 Permit
• State Stormwater (Post -Construction) Permit
Other
Permit Number* NCG020000
Begins with "SW", "NCG", or "NCS'
What DEQ Office is Reviewer: Please correct if misidentified, close this review form, and reassign task to the appropriate contact.
the Primary Contact? • Central Office
*
Washington Regional Office (Attn: Carl Dunn)
Wilmington Regional Office (Attn: Christine Hall)
Project Name* Quarterly Summary Discharge Monitoring
Owner/Operator* Sibelco North America
County: Mitchell
Submitter Name: * Jody Mckinney/Rick Singleton
Who is submitting this information?
E-mail Address:* [e-mail]
Phone Number* 8287654251
Additional E-mail for [e-mail]
Submittal (Optional)
Confirmation:
State Stormwater (Post -Construction) Information Uploads
Choose file type and upload attachment (Reviewer may remove unnecessary submittals)
File Type* Stormwater Report
File Upload Click the upload button, or drag and drop files to attach
2021 Stormwater QFP signature.pdf 404.9KB
Only PDF files are accepted.
Uploads contain • NO
Confidential YES
Information* NOTE: The following information cannot be claimed as confidential: the name and address of any permit applicant
or permittee, permit applications, permits, effluent data, information required by NPDES application forms provided
by the Director inclusive of all forms and attachments [Ref. 40 CFR 122.7(b) and (c)].

Notes about the attachments:
* By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
• 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');
• 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 Upload form.
Full Name:* Dustin Jody Mckinney
Signature:
r✓�rzcrliia� ��c�� �,e'
Date Submitted: 10/28/2021

Initial Review
Verify Permit No.* IMPORTANT. REVIEWER SHOULD VERIFY and revise here if necessary.
NCG020793
Who needs a Copy?* Reviewer selections will only be required for offices checked here.
Central Office Staff
Regional Office Stormwater Contact
State Stormwater RO Staff
No Copy Needed
Review Date* 01/05/2022