20180689 Ver 1_Other_20190506

Staff Review
DWR Project #: * 20180689
Version: * 1
Reviewer List* Stephanie Goss: eads\szgoss
CERTIFICATION SUBMITTED ON 5/6/2019
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 submit it to the DWR 401 & Buffer Permitting
Branch. This form may be returned to DWR by the applicant, the applicant's authorized agent, or the project
engineer. It is not necessary to send certificates from all of these.
Is this a Public Transportation Project?
Yes
No
DWR Project #: 180689 Version: 4132
County: Northampton
401 Water Quality Certification Issued Date: 7/27/2018
Applicant: NC Wildlife Resources
Commission
Project Name: Henrico BAA -Site Renovation
Supplemental Attachments: Click the upload button or drag and drop files here to attach document
PDF only
Who will be submitting the Certification of Completion?
U Applicant
U Agent
v Certified Professional
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.
.✓ By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of the "Certificate of Completion" form is a "transaction" subject to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act')
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC
General Statutes (the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as
a written signature; AND
• I intend to electronically sign and submit the "Certificate of Completion" form."
Printed Name: Brad Kleinmaier
Signature
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