20191495 Ver 1_U5537_CEI Access and Agent Authorization Form_Signed_20191104

�1GAROLINA
�JECOSYSTEMS
3040 NC Hwy 42 West; Clayton, NC 27520
P:919-359-1102 — F:919-585-5570
PROPERTY ACCESS AND AGENT AUTHORIZATION FORM
Property Information
Property Address
and/or Description
Parcel Identification
Number(s) (PIN)
Lake Pine Drive
Various - Ri2ht of W
City: Apex State: NC County: Wake Property Size (Acres): 9.2
Property Owner Information
Owner: ® Authorized Agent*: ❑
Name: Town of Apex - Russell Dalton, P.E.
Title: Senior Transportation Engineer
Street Address: 73 Hunter Street
City: Apex State: NC Zip Code: 27502
*Written proof of authorization from owner required.
Authorization
I, 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.
Digitally signed by Russell Dalton
l ton ern Russell Dalton, o=Town Apex, ou,
Russell Damail=[e-mail], c=US
Owner/Agent (signature) Date: 2019.10.23 15:16.43 -04'00' Date