Franklin Medical Center – 20 Bed Expansion - 12/6/2018 2:04:21 PM

Submittal Dated: 12/6/2018
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 — 20 Bed Expansion
County: Franklin
Name: Adam Henriksen
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 docurrant
2018-12-07_Stormwater Narrative.pdf 5.64MB
2018-12-07—Stormwater Comment Response.pdf 80.3KB
2018-12-07 Franklin Medical Stormwater Permit
— 38.82MB
Resubmittal.pdf
Only pdf files are accepted.
Describe the attachments:
Attached are the Revised Plans and a Revised Drainage Report, along with a comment response letter for Corey
Anen's comments to Franklin Medical Center 20 Bed Addition.
* 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:* Adam Henriksen

Signature:
AcJaw W'eo�ksep
Date Submitted: 12/6/2018

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW5181001
Who needs a d Central Office
copy?* rJ Regional Office
Central Office Reviewer:
Corey Anen - eads\scanen
Select Reviewing Office*
Raleigh Regional Office — 919-791-4200
Select RO Reviewer:*
[e-mail]