20050104 Ver 1_Certification of Completion_20071029

Mr. J.M. Mills, P.E.
February 9, 2005
DWQ# OS-0104
Page 4
DWQ Project No.:
Applicant: /t
Project Name:` _
Date of Issuance of 401 Water Quality Certification:
County: t,~~ G(, [ , ~
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401/Wetlands Unit, North Carolina
Division of Water Quality, 1621 Mail Service Center, Raleigh, NC, 27699-1621. This form may be returned to DWQ by
the applicant, the applicant's authorized agent, or the project engineer. It is not necessary to send certificates from all of
these.
Applicant's r~ifi ation
I, ~ f' ,hereby state that, to the best of my abilities, due care and diligence was
used in th o s rv tion of the construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and specifications, and
other supporting ma 'als.
Signatur . Date: ~/ ~~ v
Agent' s ~ C erti fi c at~bn
I, ,hereby state that, to the best of my abilities, due care and diligence was
used in a ob ervation of the construction such that the construction was observed to be built within substantial
complianc and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and specifications, and
other supporting materials.
Signature:
Engineer's Certification
Partial Final
Date:
I, , as a duly registered Professional Engineer in the State of North
Carolina, having been authorized to observe (periodically, weekly, full time) the construction of the project,for the
Permittee hereby state that, to the best of my abilities, due care and diligence was used in the observation of the
construction such that the construction was observed to be built within substantial compliance and intent of the 401 Water
Quality Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature
Date
Registration No.
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