Randy Marion Ford Lincoln Dealership - 3/25/2019 8:58:44 AM

Submittal Dated: 3/25/2019
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
SW3190202
Examples: SWxxxxxxx, NO&xxxxx, or NOSxxxxxx
Facility Name:* Randy Marion Ford Lincoln Dealership
County: Iredell
Name: Donald Munday
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
RM-SSW-SuppEZ-20170329-DEMLR-SW-rev-
281.08KB
SEALED.pdf
Only pdf files are accepted.
Describe the attachments:
Corrected Supplement-EZ Form to indicate SCM is "not' located on or near contaminated soils.
* 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:* Donald L. Munday
Signature:
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Date Submitted: 3/25/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW3190202
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]