Hopkins Assisted Living Community - 11/20/2018 3:30:00 PM

Submittal Dated: 11/20/2018
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 perrrit nunber for this project.
.........................................................................................................................................................................................................................................................................................................................................................................
D# * FL-rrrit Narrber
SW5181102
Exarrples: SWxxxxxxx, NOQaxxxx, or NOSxxxxxx
Facility Name:* Hopkins Assisted Living Community
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 docurrent
2018-11-20 Signed Stormwater Mgmt Permit
5.02MB
Application.pdf
Only pdf files are accepted.
Describe the attachments:
executed application.
* 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
• I intend to electronically sign and submit the Supplemental Information form."
Full Name:* John Benton
Signature:
O

Date Submitted: 11/20/2018

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW5181102
Who needs a d Central Office
copy?* rJ Regional Office
Central Office Reviewer:
Corey Anen - eads\scanen
Select Reviewing Office*
Raleigh Regional Office — 919-791-4200
Select RO Reviewer:*
[e-mail]