20110588 Ver 1_Certification of Completion_20110629 (2)

NCDWQ Project No.: 1I osg g County:
Annlivant! T> ; / s ?e
Project Name: XT 1801 6rook, 9,0
Date of Issuance of 401 Water Quality Certification: U3vl,e ?-q 1l
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 may be 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.
Applicant's Certification
1, S-Eovle•Nat 1 MoALL,s , 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 p ns and specifications, and other supporting materials.
Signs ure: _ __ Date:
1 B ZO 13
Agent's Certification
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:
Engineer's Certification
Partial Final
1, , 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 Permttee 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
f�
2013
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