20120357 Ver 1_Certification of Completion_20121126

NCDWQ Project No Z01L03 57
Applicant g/c .DaT :':>t V 5
County
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Protect Name SR /It-1 A%•r AU' 'e-we')
Date of Issuance of 401 Water Quality Certification _ 0!111 /I Z
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 Transportation Permitting
Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC, 27699 -1650 This form
maybe returned to NCDWQ by the applicant, the applicant's authorized agent, or the project engineer It is not
necessary to send certificates from all of these
Appkcant's Cert ation
I, �. ail/. wma�1, 1� E. , 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 L Date
Agent's Cert fcation
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
Engineer's Certification
Partial Final
Date
I, , as a duly registered Professional Engineer 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
Signature
Date
Registration No
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