20060387 Ver 1_Certification of Completion_20071102

Certificate of Completion
DWQ Project No.:
C~C~~-o3s7
County: ~J 1 ~ ~~~
Applicant: ~ G ~ I ~ ~~ S l 0~ Z~ t` f (jl~-e'S1 ~5ac.3 (-(,~~
i L( _ j1 1 1 l
ProjectlV'ame: ~~ ~r'lt~Se ~ c3~ ~v~ 12C~.( ~.f eels ~"~~eo~(~ tc~S1®t-r~Tlvr`„
Date of Issuance of 401 Water Quality Certification: - 0.y I ~ ~. O O~]
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the Winston-Salem Regional
Office, North Carolina Division of Water Quality, 585 Waughtown Street, Winston-Salem NC, 27107. This
form may be returned to DWQ 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
diligence was used
within substantial
approved plans a
n t e obse 'a1
m i nc and
~g ~ ions..
_, hereby state that, to the best of my abilities, due care and
istruction such that the construction was observed to be built
401 Water Quality Certification and Buffer Rules, the
on o rt i_~_n~m at_eri al s .
Signature:
Agent's Certification
Date: ~6 ` ~-67
I,~~~ ~ ~ L'7e~,,~ f~`-~ ~~ ,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: c~ Date: ~~~l,.a, u Y ~ ~~
~~
~' ,, ~r' ~ 1001
If this project was designed by a Certified Professional t,~~,,~.; ~a,; .,;~ 4:~ut,~«-~.
,,~~ry ~~t~,{a~~va~F_a~R4~CN
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 Permittee hereby state that,
to the best of my abilities, due care and diligence vas 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.
Sinature: Registration No.: Date: