WQ0019908_Monitoring - 10-2020_20201110

FORM: NDMR 10-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Page of
Sampling Person(s) Certified Laboratories
Name: NA Name: NA
Name: Name:
..w,.,.,4in Affnrhmmnf A of vnur narmif? F ompliant ❑Non -Compliant
L)Ueb dill 111U[MV11119 UQIQ 4211u 001111i 117y 11'iMY�i..w4JIf the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
N 0 V 1 0 2020
DJti '�i ; vCUTI I I
IN TORT MT110 f! PR(3r,F 31 U;1
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: �/ S
Permittee: Holt Lake Golf & Rec. LLC DBA Johnston Co. Country Club
C �e U
Certification No.: NA
Signing Official: j 5 ► I
7
Grade: NA Phone Number: 3 ✓ `� l
Signing Official's Title:
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Has the ORC changed sin a the previous NDMR? ❑yes L'�No
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Phone Numb Permit Expiration:
S g ture Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that all qualified personnel properly gathered and evaluated the information
submitted Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am
aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for
knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page __ of
Permit No.: Vb QtG 19908
Facility -Name: Johnston County Country Club County: Johnston Monch: 7eai: a
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