20231599 Ver 1_20231128_AGENT AUTHORIZATION FORM_20231128

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Qualify
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
DEED NO. _2144/502 PLAN NO. PARCEL ID: 5667-67-0337_
STREET ADDRESS: _Page Road Washington, NC 27889
Please print:
Property Owner:
Property Owner:
Jimmie W. Brewer
Audrey T Brewer
The undersigned, registered property owners of the above noted property, do hereby authorize.
Marie Peedin Inner Banks Engineering, PC
of
(Contractor / Agent)
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance, and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
3500 Rockwood Ct, Greenville, NC 27834
252-946-8937
Telephone:
We hereby certify the above information submitted
best of our knowledge.
Jimmie Brewer
Authorized Print Name Au orid Signature
true and,6cdurate to the
D North Garonne Department of Environmental Quality mils Washington.
Resources
_ Washington Regional Office 9d3 Washington Square Mall Washington. North Carolina 27889
252.946.6481