20140408 Ver 1_Certification of Completion_20150616

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NCDWR Project No.: � � (.��
ApplicanE:
Project Name:
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Date of Issuance of 401 Water Quality Certi6cation:
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County: �
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Certificate of Completion
Upon completion of all wark approved within the 401 Water QualiTy Certification or applicable Buffer Rules, and
any subsequent modificafions, the applicant is required to return this certificate to the 401 Transportaflon Permitting
Unit, North Carolina Division of Water Resources, 1650 Mail Service Center, Raleigh, NC, 27699-1650. This form
may be returned to NCD WR by the applicant, Yhe applicanYs authorized agent, or the proj ect engineer. It is not
necessary to aend certificates from all of these.
App[icant's Certification
I, ��. (� �� �'sL � , hereby state that, to the best of my abiliries, due care and diligence
was use 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: �1 r � � "� � �
Age�eYs Cert�cation
I, hereby state that, to the best of my abiflYies, due care and dIligence
was used in the observarion of the conshvcfion 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 Certifzcation
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 conshuction 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