SWA000097_Supplemental Info Review_20210323

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/23/2021 9:49:28 AM (Supplemental Submittal)
Submit by McCoy, Suzanne 3/23/2021 10:16:15 AM (Supplemental Info Submittal)
• The task was assigned to McCoy, Suzanne 3/23/2021 9:49 AM

Submittal Dated: 3/23/2021
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 suDDly the Derrrit nunber for this Drolect.
D# * Perrrit N irrber
SWA000097
Examples: Sftxxxxxx, NC Gxxxxxx, or NCSxxxxxx
Facility Name:* Hennessy International
County: Alamance
Name: Nicholas Scheopner
Vft is subrritting the infornetion?
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 docurrent
OMA signed.pdf 4.59MB
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 infornetion cannot be claimed as confidential: the nave and address of any permt applicant or
perrrittee, perrrit applications, perrrits, effluent data, information required by NRJES application forms provided by
the Director inclusive of all forrrs and attachments [Ref. 40 CFR 122.7(b) and (c)].
Describe the attachments:
The operation and maintenance agreement for the Hennessy International Warehouse Project
* W 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');
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
• I intend to electronically sign and submit the Supplemental Information form."

Full Name:* Nicholas William Scheopner
Signature:
is+F�rsc� �f
Date Submitted: 03/23/2021

Initial Review
Updated ID#: WFORfANT. REV1RAERSH0LLDVMFY and revise here if necessary.
SWA000097
Who needs a W Central Office
copy?* r Regional Office
Central Office Reviewer:*
Corey Anen - eads\scanen
Review Date * 03/23/2021