20201842 Ver 1_Agent Authorization_20210112

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL I.D.
STREET ADDRESS:
Property Owner (please print):
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):
Telephone:
We hereb} certify"the'above in
our knowledge.``
Owner Authorized Signature
Print Name
Date
in this application is true and accurate to the best of
a,, ij .
SEGi Authorized Signature
David Scibetta
Print Name
Date