20181054 Ver 1_Agent Authorization_20180731

AGENT AUTHORIZATION
This form authorizes Pilot to act as our agent in stream/wetland matters including U.S. Army
Corps of Engineers and North Carolina Division of Water Resources field verification and
permitting.
Property Address:3309 Gaston Road
Greensboro .NC 27407
Owner lnformation:
Address Iim and fufelissa Rahcock
Telephone Number:(136) A5).-17',7\
Fax Number:
E-mail Address:ibabcock@ stayalertsafety.com
J U RISDICTIONAL DETERMINATION REQUEST
D. PROPERW ACCESS CERTIFICATION
By signing below, I authorize representatives of the Wilmington District, U.S. Army Corps of
Engineers (Corps)to enter upon the property herein described for the purpose of conducting on-
site investigations, if necessary, and issuing a jurisdictional determination pursuant to Section
4A4 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899. l, the
undersigned, am either a duly authorized owner of record of the property identified herein, or
acting as the duly authorized agent of the owner of record of the property.
Print Name
Capacity: X Owner _ Authorized Agent
o - 16
Date
Signature