NCG160237_Supplemental Info Review_20210113

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/13/2021 9:15:42 AM (Supplemental Submittal)
Submit by McCoy, Suzanne 1/14/2021 3:35:40 PM (Supplemental Info Submittal)
• The task was assigned to McCoy, Suzanne 1/13/2021 9:16 AM

Submittal Dated: 1/13/2021
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
NCG 160237
Examples: SWxxxxxxx, NCa <xxxxx, or NCSxxxxxx
Facility Name:* Burlington North
County: Caswell
Name: Scott Martino
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
Burlinton North 1600 NOI application.pdf 45.85MB
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 permt 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:* Scott Martino
Signature:
Date Submitted: 01/13/2021

Initial Review
Updated ID#: IWORfANT. RE\/1RAE 2SH0LLDVMFY and revise here if necessary.
NCG160237
Who needs a W Central Office
copy?* r Regional Office
Central Office Reviewer:*
Michael Meloy - eads\mkmeloy
Review Date * 01/14/2021