20230710 Ver 1_Agent Authorization Form signed_20230518

DocuSign Envelope ID: DB9E7771-53B4-40B0-8379-7ED295400566
VF—
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: 242.38 AC., PB 45/97, ON SR 1571
LOT NO. PLAN NO. PARCEL I.D. 3270-68-9374-0000
66 SCOTTS HILL LOOP RD, Wilmin tong NC
STREET ADDRESS: 22, ...
Property Owner (please print):.,_ FOYm FAMILY LTD PTNRP
The undersigned, registered property owner of the above noted property, does hereby authorize
Southern Environmental Grou Inc. SEGi to act on their behalf in matters regarding areas of
environmental concern.
Property Owner's Address (if different than property above):
2266 ITSCOTTS: HILL LOOP RD _ITITITITIT
Wilminton� NC mmmm_�IT_
Telephone:
: IQ Lo g
We hereby certify the above information submitted in this application is true and accurate to the best of
4a�
Property Owner Authorized Signature SEGi Authorized Signature
Robert Foy David Scibetta
.... �.. �.... ��.. ,,, .. �w _........
Print Name Print Name
2/8/202z
.................. 02/08/2022
Date Date