SW3190504_Supplemental Info Review_7/10/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/10/2019 4:24:06 PM (Supplemental Submittal)
Submit by Strickland, Shane 7/12/2019 10:58:36 AM (Supplemental Info Submittal)
• The task was assigned to Strickland, Shane 7/10/2019 4:24 PM

Submittal Dated: 7/10/2019
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
SW3190504
Exarrples: SWxxxxxxx, NOC;axxxx, or NCSxxxxxx
Facility Name:* Line 118 retrofit
County: Union
Name: Dan Jester
Who is subrritting 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
Delegation of Signatory Responsibility. pdf 39.92KB
existing exhibit.pdf 330.16KB
Only pdf files are accepted.
Describe the attachments:
plan showing existing condition.
delegation of signatory responsibility
* V By checking the box and signing box below, I certify that:
o 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)
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');
• 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:* Dan Jester

Signature:
mt= �[l.&
Date Submitted: 7/10/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW3190504
Who needs a d Central Office
copy?* F Regional Office
Central Office Reviewer:*
Corey Anen - eads\scanen
Select Reviewing Office*
Mooresville Regional Office — 704-663-1699
Select RO Reviewer:*
[e-mail]