20160254 Ver 1_Certification of Completion_20160610

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NCDIVR Projcc� No.: uZL�� 'U�_�1�
ApplicanL• _�C���L� --
Projecl Namc:
D.{le of Issunnce of 401 �Va�er Qualily Certificalion:
PA'I' nACCROR},
DONAI,U K. VAN DGR VAAR"I�
County: �i{c"�_tf
J
S. IAY GIMibIGRMAN
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Certificatc of Complction
Upon completion of nll work approved within the d01 \Va�er Qu�lily Certifcalion or applicable [3ulfer Rules, nnd
any subsequent modifications, Ihe applicant is required �o relurn Ihis eertificale to lhe 401 Transporlation Pennitting
Unit, North Carolina Division of \Vnler Resources, 1617 �4ail Service Center, Raleigh, NC, ?7G99-1G17. 7'his fonn
may be relurned lo NCD\YR by �he applicanl, the applicant's authorized agenL or Ihe project engineer. It is not
necessary �o send cerlifica�es from all of these.
ApplicnuPs Cer�ifrcnlio�i
�, ���.S�/��>�iis , hereb�• staie �hat, to ihc best of my nbilities, due care and diligence
�vas used in the observa[ion of �he consin�ction such that the construction �vas observed to be buil[ �5�i�hin subslantial
compliance and intent of �he d01 \Vater Qualily Cc�titication and l3uRer 2ules. Ihe approved plans and
specilicalions, and o�hcr supporti �g in t�i� Is.
Signalure: � f/� � tiin� _ Dale: � "_��� � ��
�Ige�iPs Cerlificrdio��
�� , hereby slate tha�, to ihe besl ol my abililies, due care and diligence
was used in the ubservation of �he construction such iha� �he construciion was observed io be built within substanlial
compliance and inlent of Ihe d01 �Valcr Quality Ccrlification and [3uttcr Rules, the approved plans mid
specificnlions, �md other suppurting nmterials.
Si�nalure:
L•r�gineer's Cerlificalion
Pmtinl �inal
�� , as a duly regis�ered Professional 8ngincer in �he State of North
Carolina, having been awhm�ized to o6seive (periudically, ���eckly, full time) the construction of Ihe project f'or the
Permitlee hereby slatc Ihat, lo Ihe besl of my abilitics, due care and diligence was useA in Ihe observa�ion of �he
construc�ion such th�u ihe conslruction �ras observed to be built wi�hin substanlial compliance and inlent of lhe 401
\5'ater Qualiiy Certification �md 6u0ir Rules, the approved pl�ns and specilications, �md u�her siq�poi7ing materials.
Si�nmure
Dnte
Regislrnlion No.
Stal: of Nnnh C:uulina fmironin:mal (jualin� I lY:ncr Rcu�w...
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