20230482 Ver 1_Agent Authorization (2)_20230330

TIMMONS GROUP
YOUR VISION ACHIEVED THROUGH OURS.
AGENT AUTHORIZATION and
PROPERTY OWNER CERTIFICATION FORM
All Blanks to be Filled in by Current Landowner
The Department of the Army
US Army Corps of Engineers
Wilmington District
PO Box 1890
Wilmington, NC 28402-1890
To Whom It May Concern:
NCDEQ — Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I, the undersigned, current property owner designate, authorize representatives of Timmons
Group to act on my behalf as my agent in the processing of permit applications, to furnish upon
request supplemental information in support of applications, etc., from this day forward.
This the 0 1 day of Agee4 , 20,?,a.
(number) (Month) (Year)
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)
and NCDEQ Division of Water Resources (DWR) 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 401 and 404 of the Clean Water
Act, and/or Section 10 of the Rivers and Harbors Act of 1899.
This notification supersedes any previous correspondence concerning the agent for this project.
Project Name: Circle K Goldsboro NC
Parcel ID: 2598334777
Site Address: 0 Arrington Bridge Road
Goldsboro, NC 27530
Property Owner's Name (Print): Wilson Woodrow Jr.
Property Owner's Signature:
Property Owner's Mailing
Address: ,(21 4A 6.
Property Owner's
Telephone: , 2 S'
Property Owner's
Email Address: 1A f ^,4 %l / fJ
Fax
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