20120313 Ver 1_Certification of Completion_20150611

Certificate of Completion
DWQ Project No. � � °' Qo�� �? County: �j � �� '�
Applicant: ���iC% 1
Project
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Date of Issuance of 401 Water QuaGty CertiTicatiom: �f ��( ',.��
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules,
and any subsequent modificarions, the applicant is required to return this certificate to the
401/Wetlands Unit, North Cazolina Division of Water Quality, 1621 Mail Service Center, Raleigh,
NC, 27699-1621. This form may be returned to DWQ by the applicant, the applicanYs authorized
agent, ar the project engineer. It is not necessary to send certificates from all of these.
App[icanNs Certification
I, j� � �, (n�z %t 4��r'� , hereby state that, to the best of my abilities, due caze and
diligence was used in the observation of the construction such that the construc6on was observed to
built within substantial wmpliance and intent of the 401 Water Quality Certification and Buffer
Rules, the approved plans and specifications, and other snpporti�g materials.
Signature: � � �'1��,
Agent's Certifzcation
Date: f t! ~ ��% ` �S�
I, , hereby state that, to the best of my abilifies, due care and
diligence was used in the observation of the construction such that the construction was observed to
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:
If this project was designed by a Certified Professional
Date:
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 rime) the construction of the project, for the
Permittee hereby state that, to the best of my abilities, due caze and diligence was used in the
observation of the construction such that the construction was observed to 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: