20180698 Ver 1_Agent Authorization Form_20180710

AUTHORIZATION TO ACT AS REPRESENTATIVE FORM
Property Legal Description:
DEED BOOK: 118 PAGE NO:
PARCEL ID: 9500-49-9369
STREET ADRESS: 174 Sandollar Road
Please Print:
Property Owner: Ashlee Evans
Property Owner: Russell Evans
The undersigned property owners of the above noted property, so hereby authorize
Doug Dorman of Atlantic Environmental Consultants, LLC to,
(Contractor/Agent) (Name of consulting firm)
1. Act on my behalf and take all actions necessary for the processing, issuance and
acceptance of permits and/or certifications and any all standard and special
conditions attached.
2. Enter the property to obtain site information including inspections with regulatory
agencies (Dare County, North Carolina Department of Environmental Quality,
U.S. Army Corps of Engineers, etc.) for the purpose of obtaining permits and/or
certifications.
Property Owners Address (if different than property above):
3414 Widgeon Street,Wilson, NC 27893
Property Owners Telephone Number: 252-202-6922 / 417-860-8396
We hereby certify that the above information submitted in this application is true and
accurate to the best of our knowledge.
Authorized Signature and Title
Date:
Authorized Signa re and Title
Date: