20221723 Ver 1_Fox Run Applicant Agent Authorization Signed_20221205

DocuSign Envelope ID: B75F9D2E-3A34-4927-805E-677CE2B253F9
,5F—V 1
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: TR-P/0 1-6 50.91AC PL 51/66 SR 1133 & SR 1130
LOT NO. PLAN NO. PARCEL I.D. 19900127
STREET ADDRESS: Mount Pisgah Rd, Supply NC
Applicant / Potential Buyer (please print): R&S Land Development, LLC
The undersigned, registered property owner of the above noted property, does hereby authorize
Southern Environmental Group, Inc. (SEGi) to act on their behalf in matters regarding areas of
environmental concern.
Property Owner's Address (if different than property above):
107 Farmington Blvd
Hampton VA 23666
Telephone:
719)499-1373
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge. yn
DocuSigned by: DocuSigned by: � A
�r cTL/J
6BProj®*.Owner Authori n u SEGi Authorized Signature
Dr.David Gore Brenda Gore
David Scibetta
Print Name Print Name
11/18/2022 1 2:52 PM EST 11/18/2022 1 2:58 PM EST 11/15/2022
Date Date