WQ0019908_Monitoring - 02-2022_20220328

FORM- NDMR 10-13
NON -DISCHARGE MONITORING Ri FVK t tNumrcf
Sampling Person(s)
Namo: NA
Name: NA
Certified Laboratories
Namo: '
Name:
mpling frequencies meet the requirements In Attachment A of your permit? �ompuant ONO
Does all monitoring data and sa�r�t Rt
If the facility is non -compliant, please explain in the space below the reasons) the facility was not In compliance. Provide In your explanation the date(s) of the non -Compliance and describe the
action(s) taken. Attach additional sheets if necessary.
Operator In Responsible Charge (ORC) Cortification
ORC: 4Ayti 5 � )
Certification No.: NA
Grade: NA Phone Number:
Has the ORC changed since ote previous NDMR? Elyes Oa
Date
ey lids signature. i eerttfy that tMa report 13 acaarate and compfele to the best Of my k-Medga.
permittoe Certification
Pennitteo: Holt Lake Golf & Rec. C(LLC DBA J ston Co. Country Club
signingOfffciai: CHI(J5 ,'� ! OA'S ((/
signing Officials Title: 6e,,&,,;
Phone Number: —t[S3gr Permit Expiration:
Signature' Dale
I cattHy, under parks ty or l._. that ft do�urnerd and ell atlachmonts worn prepared under my d'.rao:ton or
accardarca w".h a aystem dosignod toassuro that all qualified pareonnai pmperfy gaUiered and ove:uated he kgalmatlon
suhmittad. Sasod an my tnqu'ry of the person or We= who marwga the system, cr those parsom dbectty retWe% f
gathartog the tniormation, the Informallen submdtsd Is, to the boar of my knardledgo and b9al, true, 00=810. am CO�plelaa
aware that there are slgrr!.+ Td panallias far sulm:" fall �a� IrckidlN the possibility of !from and �� l a
�
Malt Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617