20151012 Ver 1_More Info Received_20151002

Montalvo, Sheri'A
From: Chris Hopper <chris.hopper @carolinaeco.com>
Sent: Friday, October 02, 2015 11:26 AM
To: Montalvo, Sheri A; phil.may @carolinaeco.com
Subject: RE: Water Transmission System Improvements near Thomas WTP & WSSU
Attachments: Agent- authorization_form.pdf
Ms. Montalvo:
Attached, please find the requested Agent Authorization form. Please let me know if you have questions or require
additional information.
Regards,
Chris
Phil May
Carolina Ecosystems, Inc.
(919) 606 -1065
From: Montalvo, Sheri A fmailto :sheri.montalvo @ncdenr.govI
Sent: Tuesday, September 29, 2015 10:25 AM
To: r il.mav(�bcarolinaeco.com
Subject: Water Transmission System Improvements near Thomas WTP & WSSU
Importance: High
Phil,
We have received the PCN and fee for the above project. With Ron Hargrove's signature on the signature page 10 of 10
we will require the attached agent authorization form to be filled out. You can email it back to me at
sheri.montalvo @ncdenr.Rov once completed and I can take the project off hold.
Thanks,
S" J tmdatw
Sheri Montalvo - Administrative Assistant
401 & Buffer Permitting Unit
NCDEQ - Division of Water Resources
1617 Mail Service Center, Raleigh, NC 27699 -1617
Phone [phone]
Email• sheri.montalvo @nedenr gov
E -mail correspondence to and from this address may be subject to public records laws and may be disclosed to third
parties.

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CAROLINA 3040 NC: Hwy 42 West; Clayton, NC 27520
INC. P:919- 359- 1102 — F:919 -585 -5570
PROPERTY ACCESS AND AGENT AUTHORIZATION FORM
Property Information
Property Address
and /or Description New easement near and along Brushy Fork in the Winston Salem University area
Parcel Identification
Number(s) (PIN) Multiple: Linear Easement being acquired (See PCN Mapping)
City: Winston Salem State: NC County: Forsyth Property Size (Acres): 2.75
Property Owner Information
Owner: ❑ Authorized Agent *:
Name: Mr. Ron Hargrove
Title: Utilities Director, City of Winston Salem
Street Address: P.O. Box 2511
City: Winston Salem State: NC Zip Code: 27102
*Written proof of authorization from owner required.
Authorization
1, the undersigned, a duly authorized owner of record of the property /properties identified herein, do authorize
representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps) to enter upon the property herein
described for the purpose of conducting on -site investigations and issuing a determination associated with Waters of the
U.S. subject to Federal jurisdiction under Section 404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors
Act of 1899.
Additionally, I hereby grant Carolina Ecosystems, Inc. (CEI) staff, their designated contractors and representatives, as
well as other Federal, State or local authorities access to the above referenced property when necessary for the purposes of
conducting on -site environmental consulting services. I also grant CEI the authority to act as authorized agent on behalf of
the owner of the above listed property for the communication, submission, and/or application to relevant government
entities, including local, state, and federal authorities, for the review, acceptance, concurrence, and /or approval of
environmental information, documents, and/or permit requests concerning the above listed property. These services may
include regulatory determinations of environmental features on my property such as issuing a determination associated
with streams and wetlands. I certify that I am the legal owner or authorized agent of the legal owner of the above; property
and have authority to grant such access. I have made CEI aware of, and supplied all available records related to, previous
environmental investigations on the subject property of which I have knowledge.
Owner /Agent (signature) Date - J p
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