NCG020941_Supplemental Info Review_7/28/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/28/2019 12:03:25 AM (Supplemental Submittal)
Submit by McCoy, Suzanne 7/29/2019 9:15:32 AM (Supplemental Info Submittal)
• Georgoulias, Bethany reassigned the task to McCoy, Suzanne 7/29/2019 9:02 AM
• The task was assigned to Strickland, Shane 7/28/2019 12:03 AM

Submittal Dated: 7/28/2019
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 perrrit nunber for this project.
D# * FL-rrrit Narrber
NCG020941
Ecarrples: SWxxxxxxx, NOC;axxxx, or NCSxxxxxx
Facility Name:* Keller Mine
County: Rowan
Name: Samar Bou-Ghazale
Who is subnitting the inforrration?
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 docurrant
keller-mine-SETbf.pdf 6.9MB
Only pdf files are accepted.
Describe the attachments:
Mine Map
* V 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
• I intend to electronically sign and submit the Supplemental Information form."
Full Name:* Samar Bou-Ghazale
Signature:
, z0va is O'?z r G
Date Submitted: 7/28/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
NCG020941
Who needs a V Central Office
copy?* F Regional Office
Central Office Reviewer:*
Shane Strickland - eads\sstrickland9
Select Reviewing Office*
Mooresville Regional Office — 704-663-1699
Select RO Reviewer:*
[e-mail]