20150856 Ver 1_Certification of Completion_20151110

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North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
DWR Project No.: %S d856 County:
Applicant:
Project Name:
Date of issuance of 401 Water Quality Certification:
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Suffer Rules, and
any subsequent modifications, the applicant is required to return this certificate to the DWR Central Office—
Wetlands and Buffers Permitting Unit at 1650 Mail Service Center, Raleigh, NC 27699 -1650. This form may be
returned to DWR 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, _T %S'D ,hereby state that, to the best of my abilities, due care and
diligence was 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
pians and specifi ions, and other supporting materials.
Signature: �� Date: °2
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:
H this project was designed by a Certified Professional
11 , as a duty 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: Registration No.
Date
Fayetteville Regional Office
225 Green 9"4 Suiie714, Fayetteville, Nor$ Camliina 24301 -5095
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