0011 Ver 0_SPK Real Properties Holdings Agent Authorization Form signed_20231006

5EG
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: LOT 4 ELM GROVE FARMS RECOM
LOT NO* PLAN NO. —PARCEL I.D. R05006-002-020-000
STREETADDRESS: 155 Savings Street
Property Owner (please print): SPK REAL PROPERTIES HOLDINGS c/o Pat Koballa
The undersigned, registered property owner of the above noted property, does hereby authorize
Southern Environmental Group, Inc. (SEGi) to act on their behalf in matters regarding areas of
environmental concern.
Property Owner's Address (if different than property above):
6103 Market St.
Wilmington, NC 28405
Email: pkoballapcoastalkia.com
Telephone:
910-798-4705
hereby certi the above information submitted in this application is true and accurate to the best of
our owledge.
�
roperty Own r Aut jhoorrized Signature SEGi Authorized Signature
T lYZ (Gl� c3�ell �" David Scibetta
Print Name Print Name
1 5 3 6/5/2023
Date Date