20071017 Ver 1_Certification of Completion_20100917

jar
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Colleen H. Sullins
Governor Director
Dee Freeman
Secretary
DWQ Project No.: Zoo 7 10 17 County: Ur Yea y
Applicant: c oT- 3 16 9?
ProectName: i?rti lpe? '? ISSS ouv v1 10 CIAO P;der 0M ? R /40 Z -
Date of Issuance of 401 Water Quality Certification: 7u IBC Ii) 7- 0 '1:7
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
1, T, w , o w.. a.s t Q C 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 and specifications, and other supporting materials.
Signature: Date: 512/ /i
Agent's Certification
1, 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 (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, the approved plans and specifications, and other
supporting materials.
Signature
Date
401 OversightlExpress Review Permitting Unit
1656 Mail Service Center, Raleigh, North Carolina 27699-1650
Location: 2321 Crabtree Blvd., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet hup:llh2o.enr.state.nc.uslncwetlandsr
stration No.
,rr I v one
?NR "70 NorthiCarolina
"l ; ? /i Naturally
An Equal Opportunity \ Affirmative Action Employer