NCG020937_Supplemental Upload Form_20190422

Submittal Dated: 4/22/2019
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
NCG020937
Ecanples: SWxxxxxxx, NO&xxxxx, or NOSxxxxxx
Facility Name:* Funston Company Inc. Mine
County: Brunswick
Name: Adam H. Grady
Who is submitting the information?
Email Address:* [e-mail]
Please upload all files that need to be submited.
Qick the upload button or drag and drop files here to attach document
11956 PLAN BASE 09-28-18_updated owners S-
2.32MB
2.pdf
Only pdf files are accepted.
Describe the attachments:
* W 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:* Adam H Grady, P.E.
Signature:

Date Submitted: 4/22/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
NCG020937
Who needs a V Central Office
copy?* F Regional Office
Central Office Reviewer:*
Shane Strickland - eads\sstrickland9
Select Reviewing Office*
Wilmington Regional Office — 910-796-7215
Select RO Reviewer:*
[e-mail]