20041011 Ver 1_Certification of Completion_20071119

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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W..Klimek, P.E. Director
Division of Water Quality
DWQ Project No.: d�I �} 1/ County:
Applicant: . �c�- —
Project Name: S /1 Z
Date of Issuance of 401 Water Quality Certification
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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, 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, ��� t ��y , 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: ��; �1, �- Date:� ��; ��ti
AgenYs Certlficafion
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 des/gned by a Certified Profess/onal
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 Permitee 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, tlie approved plans and specifications, and other
supporting materials.
Signature Registration No. Date
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North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Maii Service Canter, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Bivd., Raleigh, NC 276042260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/ncwetlands/