2012010 Ver 1_Certification of Completion_20120730

DWQ Project No
Applicant:
Project Name:
Natural Resources
John E. Skvarla, III
Secretary
1 9% County: OY`
401 Water Quality Certification Issued Date:
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
Webscape Unit, NC DWQ 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 Certif&ation
I, 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 aridspecifications, a ldother sr pporting materials.
Signature: 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:
Wetlands, Buffers, Stormwater — Compliance and Permitting (Webscape) Unit
1650 Mail Service Center, Raleigh, North Carolina 27699 -1650
Location. 512 N. Salisbury St Raleigh, North Carolina 27604
Phone [phone] FAX: [phone] Customer Service: 1 -877- 623 -6748
Internet: www ncwaterqualiV org
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Upstream
Pipe Replacement
SR 1112, Bethany Road
Gaston County
Outlet
Inlet
Downstream