20160934 Ver 1_Certification of Completion_20170110

CERTIFICATE OF COMPLETION
NCDWR Project No.: County:
Applicant: 4Q,,
Project Name:
Date of Issuance of 401 Water Quality Certification: 1�
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or app i
Rules, and any subsequent modifications, the applicant is required to return this certificate to
Transportation Permitting Unit, North Carolina Division of Water Resources, 1650 Mail Service
Raleigh, NC, 27699-1650. This form may be returned to NCDWR 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 �f
I, , hereby state that, to the best of my abilities, due care
and diligence was used in the oVrervation 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 specification , and other supporting materials. r�
Signature: /. Date: l !
Agent's Certification
I, hereby state that, to the best of my abilities, due care
and —di—ligce walWed i e 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:
Engineer's Certification
Partial Final
I, as a duly registered Professional Engineer 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 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 Registration No.
Date