Clay County - B99 - NCDWR - 401 - Certificate of Completion Form (Signed)

DWQ Project No.: 2020-1574 County: Clay County
Applicant: North Carolina Department of Transportation – Division 14
Project Name: Bridge 99 on SR 1168 (17BP.14.R.169)
Date of Issuance of 401 Water Quality Certification: March 1, 2021

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 Planning Unit, North Carolina Division of Water Resources, 1617 Mail Service Center, Raleigh, NC, 27699-1617. This form may be returned to NCDWR
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
I, _Patrick J. Breedlove, Division 14 - Environmental Specialist II, 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: _______Patrick J. Breedlove__________________ Date: ___________11.29.2022________________
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: _________________________________
Engineer’s Certification ______ Partial ______Final

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: ______________________________________ Registration No. ________________
Date ____________________

James H. Trogdon III
Secretary of Transportation

North Carolina Division of Environmental Quality
Division of Water Resources
Roy Cooper
Governor

Internet: www.ncwaterquality.org

An Equal Opportunity \ Affirmative Action Employer

Transportation and Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]