SW5200701_Supplemental Info Review_20201006

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/6/2020 9:48:23 AM (Supplemental Submittal)
Submit by McCoy, Suzanne 10/7/2020 10:28:07 AM (Supplemental Info Submittal)
• The task was assigned to McCoy, Suzanne 10/6/2020 9:48 AM

Submittal Dated: 10/6/2020
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 Nurrber
SW5200701
Examples: SWxxxxxxx, NC Gxxxxxx, or NCSxxxxxx
Facility Name:* Bojangles at Spring Hope, NC
County: Nash
Name: Ethan Averette
Vft 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
10-6-20 Complete Set Bojangles at Spring Hope.pdf 7.6MB
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 inforrretion cannot be claimed as confidential: the narre and address of any perrrit applicant or
pernittee, perrrit applications, perrrits, effluent data, information required by WCM application forms provided by
the Director inclusive of all forrrs and attachments [Ref. 40 CFR 122.7(b) and (c)].
Describe the attachments:
* 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:* Ethan Averette
Signature:
6�# G
Date Submitted: 10/06/2020

Initial Review
Updated ID#: IWORfANT. RE\/1RAE 2SH0LLDVMFY and revise here if necessary.
SW5200701
Who needs a W Central Office
copy?* r Regional Office
Central Office Reviewer:*
Corey Anen - eads\scanen
Review Date * 10/07/2020