20150255 Ver 1_Certification of Completion_20160310

`� ••
- Affl�
NCDENR
North Carolina Department of Environment and
Pat McCrory
Governor
DWR Project No.: )s S � Cot
Applicant: to I
Project Name: tP�
Date of Issuance of 401 Water Quality Certification:
L)
Certificate of Completion
Natural Resources
Donald R. van der Vaart
Secretary
�ae�D
i o tors
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 and Buffer Permitting Unit, North
Carolina Division of Water Resources, 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 Certs kation
I, Q.AaL hereby state that, to the best of my abilities, due care and diligence was used
in the obseryt n of the construction such that the construction was observed to be built within substantial compliance and
intent of the 401 Water Quglity Certificatioq and Buffer Rules, the approved plans and specifications, and other supporting
Signature:
Agent's Certificationv
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:
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:
Date
401 & Buffer Permitting Unit
1650 Mal Service Center, Raleigh, North Carolina 27699-1650
Phone [phone] FAX [phone]
Internet http!Iportal ncdenrorg/weblwq%ws
An Equal Opportunity ! Affirmative Action Employer
Registration No.