SW4190902_Supplemental Info Review_10/1/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/1/2019 3:17:52 PM (Supplemental Submittal)
Submit by Strickland, Shane 10/2/2019 9:44:57 AM (Supplemental Info Submittal)
• The task was assigned to Strickland, Shane 10/1/2019 3:18 PM

Submittal Dated: 10/1/2019
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 nuntber for this project.
D# * Flarrrit Ninber
SW4190902
Exarrples: SWxxxxxxx, NOC;axxxx, or NCSxxxxxx
Facility Name:* Circle K - R&R 2723188
County: Forsyth
Name: Robert Wingate
Who is submitting the information?
Email Address:* [e-mail]
Please upload all files that need to be submited.
tick the upload button or drag and drop files here to attach document
Calcs-37630.025 SIA 2019-09-16.pdf 49.44MB
SSW -Deed Restric-HDCommer-37630.025-
115.75KB
SIGNED.pdf
SSW-SWU-101-Application-37630.025-SIGNED.pdf 188.93KB
PLANS-20190920-CIRCLE K- RURAL HALL.pdf 30.84MB
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 clairred as confidential: the nacre and address of any perrrit applicant or
perrrittee, permit applications, permts, effluent data, information required by Wl7 application forrrs provided by
the Director inclusive of all fours and attachnents [Ref. 40 CFR 122.7(b) and (c)].
Describe the attachments:
Calcs - calculations, supporting documents, maps, O&M manual; deed restrictions; application; Plans with details
* V By checking the box and signing box below, I certify that:
o 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")
o 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:* Robert Wingate
Signature:
d tt Ae*
Date Submitted: 10/1/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW4190902
Who needs a V Central Office
copy?* F Regional Office
Central Office Reviewer:*
Jim Farkas - eads\jjfarkas
Select Reviewing Office*
Winston-Salem Regional Office — 336-776-
9800
Select RO Reviewer:*
[e-mail]