NCG240021_Supplemental Info Upload Form_20190415

Submittal Dated: 4/15/2019
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 supply the perrrit nunber for this project.
D# * Ferrrit Narrber
NCG240021
Ecarrples: SWxxxxxxx, NOQaxxxx, or NOSxxxxxx
Facility Name:* Reidsville Yard Waste Facility
County: Rockingham
Name: Janine Schreyack
Who is subnitting the inforrration?
Email Address:* [e-mail]
Please upload all files that need to be submited.
Oick the upload button or drag and drop files here to attach docurrant
Reidsville Site Plan-Site_2018-12-14 (2).pdf 1.26MB
Only pdf files are accepted.
Describe the attachments:
Attached is the SPPP and the Site Plan and Location Map (Appendix C) as well as the Qualitative and Quantitative
testing forms (Appendix G) and the NCG24 Print Package (Appendix 1) included in the SPPP for the Facility.
* V-J By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
o 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)
o 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:* Janine Schreyack
Signature:

Date Submitted: 4/15/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
NCG240021
Who needs a V Central Office
copy?* F Regional Office
Central Office Reviewer:*
Shane Strickland - eads\sstrickland9
Select Reviewing Office*
Winston-Salem Regional Office — 336-776-
9800
Select RO Reviewer:*
[e-mail]