NCG140030_SW Permit DOSA (3)_20220629

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Wall
NCG140030 _
[e-mail]
2105 Pisgah Church Rd
Kernersville
Phone: ! 336-993-2432 ext 302
State: INC I Zip: 127284
Phone, -
State:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address: Phone:
Mailing Address:
City: State:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2
Zip:
Zip: