20130774 Ver 1_Determination Request_20130725

AG"Ar.
RCDENR
EXPRESS
JUL 2 5 2013
North Carolina Department of Environment and Natural
Division of Water Quality
ResourcesNC DENR
Pat McCrory Thomas A. Reeder
John E. Skvarla, III
Governor Acting Director
Secretary
Express Stream Origin /Buffer Applicability Determination
Required Information
1. Owner Information (corporation /individual who is legally responsible for the property and its compliance)
1 a. Names) on Recorded Deed
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1b. Responsible Party (for LLC)
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1c. Mailing Address
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1d. Telephone Number
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2. Location of Project Site - please include the county, nearest named town and highway number.
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3. Has anyone from DWQ visited the site N
Staff Name
hj Date of Visit?
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Additional Requested Information
4. Agent/Consultant Information (if applicable)
4a. Name, Company
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4b. Mailing address
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4c. Telephone no.
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4d. Email address
5. Project and Site Information k4619 ICJ, t GNU C kt
5a. Name of project
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5b. County
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5c. Nearest Named Stream
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5d. River Basin
5e. Provide a brief description of this project (attach site plan if available):
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Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.
If you are unable to locate either of these maps, please contact the Regional Office for assistance.
DWQ Use Only ;]
Please return form to: Roberto Scheller or Lyn Hardison
943 Washington Square Mall
Washington, NC 27889 Note: Submittals on Friday after 92:00 pm
Fax: [phone] will be stamped as received on the
next business day.
Email: Roberto. scheller(a ) ncdenr.aov,
Iyn.hardisonCo?ncdenr.gov
Please contact Roberto Scheller at (252) 946 -6481 If you have any questions.
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HEIDEN & ASSOCIATES LLC
NCDENR
BB &T - Checking
HEIDEN & ASSOCIATES LLC
NCDENR
BB &T - Checking
LMP100 M!P CHECK
6604
7/25/2013
DWQ Eval 200.00
EXPRESS
JUL 2 5 2013
NC DENR
200.00
6604
7/25/2013
DWQ Eval 200.00
200.00

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