SWA000064_Supplemental Info Review_1/10/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/10/2020 9:36:54 AM (Supplemental Submittal)
Submit by Strickland, Shane 1/10/2020 10:11:42 AM (Supplemental Info Submittal)
• The task was assigned to Strickland, Shane 1/10/2020 9:37 AM

Submittal Dated: 1/10/2020
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
SWA000064
Examples: SWxxxxxxx, NC Gxxxxxx, or NCSxxxxxx
Facility Name:* Roslin Farms West Section 5
County: Cumberland
Name: Kenneth Smith Jr
Vft is subrritting the infornation?
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
USGS quad map with site & coordinates - Full
62.37M6
Sized.pdf
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 narre and address of any perrrit applicant or
perrrittee, perrrit applications, pernits, effluent data, infornation required by MODES application forr s provided by
the Director inclusive of all fours and attachments [Ref. 40 CFR 122.7(b) and (c)].
Describe the attachments:
This is to fulfill Mr. Corey Anen's request for additional information; more specifically a USGS Quad map with the site
labelled as well as coordinates associated with the project. If you require anything further let me know, thank you
* Pr 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 form."
Full Name:* Kenneth Smith Jr
Signature:
Date Submitted: 1/10/2020

Initial Review
Updated ID#: WFORfANT. REV1RAERSH0LLDVMFY and revise here if necessary.
SWA000064
Who needs a W Central Office
copy?* r Regional Office
Central Office Reviewer:*
Corey Anen - eads\scanen
Select Reviewing Office*
Fayetteville Regional Office — 910-433-3300
Select RO Reviewer:*
[e-mail]