SW3201203_Supplemental Info Review_20210412

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/12/2021 12:06:06 PM (Supplemental Submittal)
Submit by McCoy, Suzanne 4/13/2021 8:35:56 AM (Supplemental Info Submittal)
• The task was assigned to McCoy, Suzanne 4/12/2021 12:07 PM

Submittal Dated: 4/12/2021
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
SW3201203
Samples: SWxxxxxxx, NC Gxxxxxx, or NCSxxxxxx
Facility Name:* Encore at Streamside
County: Union
Name: Marc Van Dine
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
2021-03-05 - CD Set - Reduced.pdf
100.65MB
Encore at Streamside Declaration 5 FEB 21.pdf
395.73KB
Encore at Streamside_SIA.pdf
28.12MB
2021-03-26 High Density Deed Restrictions
160.06KB
Form.pdf
2021-03-26 O&M Agreement.pdf
298.13KB
2021-03-26 Revised SW Application. pdf
610.04KB
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
perrrittee, perrrit applications, perrrits, effluent data, information required by NRDM application forms provided by
the Director inclusive of all forrrs and attachments [Ref. 40 CFR 122.7(b) and (c)].
Describe the attachments:

CD Set
Streamside Declaration
SIA
High Density Deed Restriction
O&M Agreement
SW Application
* 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:* Marc Van Dine
Signature:
qiG cyan Oct:
Date Submitted: 04/12/2021

Initial Review
Updated ID#: IWORfANT. RE\/1RAE 2SH0LLDVMFY and revise here if necessary.
SW3201203
Who needs a W Central Office
copy?* r Regional Office
Central Office Reviewer:*
Corey Anen - eads\scanen
Review Date * 04/13/2021