20100212 Ver 1_Certification of Completion_20121108

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NCD NR Certificate of Completion o
DWQ Project No an—mm— County Dor{
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Applicant —1h)0no S _rn, age 1-�
Date of of • Pennit
Upon completion of all work approved within the 401 Water Quality Certification and /or 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 protect engineer It is not necessary to send
certificates from all of these
Applicant's Certification
I,` T1 , hereby state that, to the best of my abilities, due care and diligence was
use in a 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 /or Buffer Rules, the approved plans and
specifications, and other supporting materials
Agent's Certification
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 /or 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 protect, for the Permittee hereby state that, to the be
and diligence was used in the observation of the construction such that the construction was
substantial compliance and intent of the 401 Water Quality Certification and/or Buffer Ru
specifications, and other supporting materials "V 0
8 70i2
Signature Registration No Date a €,.� s IAIM.�