20110027 Ver 1_Certification of Completion_20110505

V/
DWQ Project No
Applicant:
Project Name:
Certification of Completion
( (-6(011 County:
Date of Issuance of Certification or Authorization:
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n
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,UA*1-c:56 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 suppo als.
Signature: C Date: Agent's Certification

1,
used in the observation of the
compliance and intent of the 401
and other supporting materials.
Signature:
Date:
If this project was designed by a Certified Professional
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M y ZQ 11 f
I, y-xgnw
as a duly registered Professional gineer,
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.
, hereby state that, to the best of my abilities, due care and diligence was
construction such that the construction was observed to be built within substantial
Water Quality Certification and Buffer Rules, the approved plans and specifications,
Signature: Registration No. Date
Certificate of Completion