20120469 Ver 1_Certification of Completion_20121011

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P E Dee Freeman
Governor Director Secretary
DWQ Project No -- WM County M t)rA- S o mve %01
Applicant Y\(Z.e5 i)ock
Project Name 4.0��� �1 e1+�T D �/ o LO:5.} V C i
Date of Issuance of 401 Water Quality Certification
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 DWQ Central Office - Wetlands, Buffers
and Stormwater Compliance and Permitting Unit at 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
11 F( e5 4 (0 4 , 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
Agent's Certification
/0 -1- )-�2-
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
1, , 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
1650 Mall Service Center Raleigh North Carolina 27699 1650
Location 512 N Salisbury St Floor 9 Raleigh North Carolina 27603
Phone [phone] FAX [phone]
Internet www rimaterquailty org
An Equal Opportunity x Affirmative Action Employer
Registration No
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OCT 1 1 2012
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