NCG140462_Supplemental Upload Review Form 4/12/2018

ww "Arpplernental Information Upload Fon
Staff Review:
Updated ID#:
Updated Version:
Who needs a copy?*
NCG140462
1
V Central
Office
r Regional
Office
Select Reviewing Office*
Winston-Salem Regional Office — 336-776-
9800
Central Office Reviewer:
Robert Patterson - eads\rdpatterson
Select RO Reviewer:*
[e-mail]
SUBMITTED PROJECT INFORMATION
Existing Project Information:
ID# NCG140462
Version: 1
Facility Name: Redi Mix Concrete
County: Guilford
Name: Harris B. Gupton
Vft is subnitting the information?
Email Address: [e-mail]
Describe the attachments:
Please upload all files that need to be submitted.
NCG140000 complete submittal.pdf 10.66MB
Only pdf files are accepted.
Water Resources
ENVIRONMENTAL QUALITY

PF By
checking
the
box
and
signing
box
below,
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: Bryon S. Hobson
Signature:
Date Submitted: