20051031 Ver 1_Certification of Completion_20061218

Certificate of Completion
DWQ Project No.
Applicant:
Project Name:
~S- ~~ 3) County:
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Date of Issuance of 401 Water Quality Certification: (Q ~ ?~ ~ 2 0o S
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Upon completion of all work approved within the 401 Water Quality Certification and 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 Certification
I, ,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
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:
Agent's Certification
Date:
I, ,- ~ ,hereby state that, to the best of my abilities, due care and
diligence was u ed in the nervation of the construction such that the construction was observed to
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: ~~~-,~.t.~.-` Date: ~ ~~~ ~~
If this proje~fwas designed by a Certified Professional
I, , as a duly registered Professional
(i.e., Engineer, Landscape Architect, Surveyor, etc.) 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 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: Registration No.: Date: