20041177 Ver 1_Certification of Completion_20080401

Certificate of Completion
DWQ Project No.: ~ 7 -~ // 7T
Applicant:
Project Name:
County: ~ 11t4=~~
Date of Issuance of 401 Water Quality Certification:
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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, 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
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I, x~'c~~~~d ~t~' _.r'~~2~, a-tc~s~ ,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.
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Signature: A ~,SG1~~ ~ ~P~~ 1~` n~-~- Date: /~~ (h-~ ~ 7 ~~ V
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Agent's Certification ~ ~ 2 2004
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I, ,hereby state that, to the best of my abilities, QUe'' ~dCH
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 (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 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: Registration No.: Date: