Franklin Medical Center - 11/6/2018 3:38:28 PM

Submittal Dated: 11/6/2018
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
SW5181001
Exarrples: SWxxxxxxx, NOC;axxxx, or NCSxxxxxx
Facility Name:* Franklin Medical Center
County: Franklin
Name: Adam Henriksen
Who is submitting the information?
Email Address:* [e-mail]
Please upload all files that need to be submited.
tick the upload button or drag and drop files here to attach docurrant
2018-10-18_Copy of Signed Stormwater Permit
7.01 MB
App.pdf
Signed Supplement Wet Basin.pdf
1.12MB
Operation Maintenance Agreement_Signed.pdf
368.82KB
2018-10-04_Stormwater Narrative.pdf
4.17MB
Franklin Medical Center Addition Geotechnical
3.14MB
Report.pdf
Deed.pdf
419.99KB
2018-10-04_Stormwater Permit Submittal.pdf
32.87MB
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;
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

o I intend to electronically sign and submit the Supplemental Information form."
Full Name:* Adam Henriksen
Signature:
�kIrk
Date Submitted: 11/6/2018

Initial Review
Updated ID#: SW5181001
Who needs a W Central Office
copy?* W Regional Office
Central Office Reviewer:
Corey Anen - eads\scanen
Select Reviewing Office
Raleigh Regional Office — 919-791-4200
Select RO Reviewer:*
[e-mail]