20110308 Ver 1_Certification of Completion_20110506

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director
Secretary
DWQ Project No.: ` - 0_3C) g County: 1 ) r1 k'
Applicant: l2 t3&y L- ( pi-C D U t L Q S
Project Name: U k 3 ?ko aso ry C-j'
Date of Issuance of 401 Water Quality Certification: ?k - ( (? -- t I
Ccrtitiiatc 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 40 ]/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, _ AL" 14 ( LL , 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: o A.., Date:
Agent'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.
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: Registration No.
Date
1650 Mail Service Center, Raleigh, North Carolina 27699-1650
Location 512 N Salisbury St Floor 9 Raleigh North Carolina 27604-1170
Phone [phone] FAX' 919-807-6494
Internet. www ncwaterquality org
An Equal Opportunity ? Wrmalive AJon Employer
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