2023018 Ver 1_Agent Authorization Form 176 Flamingo Ln_20231106

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: TRl CHARLES DANIELS HEIRS
LOT NO. PLAN NO. PARCEL I.D. 429914247235
STREET ADDRESS: 176 Flamingo Lane
Property Owner (please print): Malpass Mark T & Sondra K
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):
176 Flamingo Ln
Sneads Ferry, NC 28460-6554
Email:
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge. )r��
Property Owner Authorized Signature
Print Name
Date
SEGi Authorized Signature
David Scibetta
Print Name
10/19/2023
Date