20230447 Ver 1_Conrad-Lynch Signed Agent Authorization_20230323

AUTHORIZATION TO ACT AS REPRESENTATIVE FORM
Property Legal Description:
DEED BOOK: 1700 PAGE NO: 233
STREET ADRESS: 806 Lighthouse Drive, Corollla, NC 27927
Please Print:
Property Owner: Chris Conrad
Property Owner: Ch ., sr�ynch
The undersigned property owners of the above noted property, so hereby authorize
)oug Dorman
(Contractor/Agent)
of Atlantic Environmental Consultants, LLC to,
(Name of consulting firm)
1. Act on my behalf and take all actions necessary for the processing, issuance and
acceptance of permits and/or certifications and any all standard and special
conditions attached.
2. Enter the property to obtain site information including inspections with regulatory
agencies (Dare County, North Carolina Department of Environmental Quality,
U.S. Army Corps of Engineers, etc.) for the purpose of obtaining permits and/or
certifications.
Property Owners Address (if different than property above):
6664 Tidewater Ln Wilmington, NC 28403
Property Owners Telephone Number:
614-653-4911
We hereby certify that the above information submitted in this application is true and
accurate to the best of our knowledge.
Authorized Signature and Title
Date: 3/21 /2023
This certification is valid thru (date)
Authorized Signa ire and Title
Date: 3/21 /2023