20160230 Ver 1_Certification of Completion_20160502

WaterResources
ENVIRONMENTAL QUALITY
WR Project No.
Applicant: S
Project Name: _
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
• 6230 0250 - NPL County:
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Date of Issuance of 401 Water Quality Certification: V 3131 / 1 � t rJ l3�
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 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 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:
Age^Certification
Date:
I, `, & /L% ���,,,;/ , hereby state that, to the best of my abilities, due care and
diligen�wa --was in the observation of the construction such that the construction was observed to be built
within substantial ompliance a intent of the 401 Water Quality Certification and Buffer Rules, the
approved plaW ang spe ' c , and other supporting materials.
I(WSignature Date: p
If this project was designed by a Certified Professional
I, ANmm:ea-� L. +} tme=p— , as a duly registered Professional egG1A�F�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 ilt within substantial compliance and intent of the 401 Water Quality
Certificatiglli-an,d Bff€er Rules, t e a&rNved plans and specifications, and other supporting materials.
Registration No.
Date� �H.,,�+
27281
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 707 9000
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