NCG140468_Supplemental Info Review_4/17/2019

Submittal Dated: 4/17/2019
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# * FL-rrrit Narrber
NCG140468
Bcarrples: SWxxxxxxx, NOC;axxxx, or NCSxxxxxx
Facility Name:* Archer Western Jonesville Concrete Batch
Plant
County: Yadkin
Name: Riley Smith
Who 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
5912 1-77 PCCP - Messick Road Yard - D1 1-40.pdf 301.56KB
Only pdf files are accepted.
Describe the attachments:
The attachment represents the current layout of the batch plant and equipment laydown area.
* 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');
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
o I intend to electronically sign and submit the Supplemental Information form."
Full Name:* Riley Smith
Signature:

Date Submitted: 4/17/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
NCG140468
Who needs a d 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]