20130903 Ver 1_Certification of Completion_20160718

A14*A*
NCDENR
V North Carolina Department of Environment and Natural, Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
DWR,Project No: Q 3 County: Va/yAm r An
Applicant:
Project Name: Sco," IGOn = QCk(1b o' VI �FaC4 GN
401 Water Quality Certification Issued Date:
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 DWR
401 & Buffer Permitting Unit, 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, E�m i'1 '[Mmol✓ (G o G) , 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 pl and specific ons, and other supporting materials.
Signa tur Date:
Agent's Certification
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: I- Date:
If this project was designed by a Certified Professional
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:
I
Division of Water Resources — 401 & Buffer Permitting Unit
1617 Mall Service Center, Raleigh, North Carolina 27699-1617
Location- 512 N Salisbury St, Raleigh, North Carolina 27604
Phone [phone] FAX [phone]
Internet www ncwaterquallty org
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