HomeMy WebLinkAboutWQ0003902_Additional Information Response_20210315Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application sites) as specified
herein. i f
Landowner name: C t- l U � 1V �(i✓ 0411 Creek W W 7V
Address: V D. RoY 5 5 D
City: h6_1 State: zip: n& 5 -
Phone: 1� 2 � E-mail address: 14 C Ae nC • ✓
Signature: Date: !! d
CTNORTH CAROLINA, W W61%� COUNTY" d
I, the undersigned Notary Public do hereby certify that W
personally appeared before me this day and acknowledged the due execution of the forgoing instrument,
WITNESS my hand and official seal this the ) Aoe! s i"�
day of
t '
Signature and seal: V, / ¢ . ? -Iko I o
My commission expires:
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Lessee's/Operator's Certification:
I certify that I have read this Agreementt and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operatorname: rp1 G
! c! if n S
Address: f g V r M j'27
City: Jew I U r ' State: �j zip: Z
Phone: J'7 E-mail address: v04&1V All h e .y
Signature: Date:
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;Permittee's Certification:
I certify that I have read this. Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official n � 1 [� /C
Signature: Date: /
FORM: LOA 06-16 Page 3 of 3