20061317 Ver 2_Certification of Completion_20091208

Certification of Completion
DWQ Project No
Applicant:
Project Name:
Date of Issuance of Certification or Authorization:
Certificate of Completion
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 Oversight/Express Permitting Unit,
North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC, 27699-1650. 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 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:
Zu09
Agent's Certification
DENR • WATER QUALITY
WETLANDS AND STORNWATER BRANCH
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 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:
If this project was designed by a Certified Professional
I, as a duly registered Professional }??r (i.e., Engineer,
Landsca Architect, Surveyor, etc.) in the State of North Carolina, having been authorize to observe (periodically,
weekly, full time) the construction of the project, for the Permiee 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, ancyother supporting materials.
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Signature: Registration No. Q; 1 .Z-7 Date