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HomeMy WebLinkAboutWQ0019908_Monitoring - 11-2022_20230211%.x f FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page L of `E' Sampling Person(s) Certified Laboratories Name: NA Name: NA Name: Name: Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? /Aompliant ❑Non -Compliant If 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. Operator in Responsible Charge (ORC) Certification Permittee Certification oRC:Ti/y✓ r71:Permittee: Holt Lake Golf & Rec. LLC DBA Johnston Co. Country Club Certification No.: NA Signing Official: Grade: NA Phone Number: Signing Official's Title: �" ►�'s�i��.'..— /—�.._. Has the ORC c ged since the previous NDMRi Eves �jo Phone Number. � � � �C' � �� �, Permit Expiration: -7 ignature 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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for Mail Original and Two Copies to: Division of Water Resources Information Processing Unit 1617 Mail Service Center Raleigh, North Carolina 27699-1617