WQ0019908_Monitoring - 01-2022_20220328

FORM: NOMR 10-13
NON -DISCHARGE MONITORING KhFVKI (Numry
Sampling Persan(s)
Name: NA
Name: NA
Certified Laboratories
Name: `
Does all monitoring data and sampiing frequencies meet the requirements in Attachment A of your permit? (ompllaat O"°rr�,r,piR�
lanation the date(s) of the nan-compliance and describe the
IF the facility is non-compliarit, please explain In the space below the reasons) the facility was not In compliance. Provide in your exp
acdon(s) taken. Attach additional sheets if necessary.
operator In Responsible Charge (ORC) Certification
ORC: 40L�t%.�i�
Certification No.: NA
Grade: NA Phone Number:
33�' ySJr�sb �
Has the ORC changed since tyre previous NDMR4 ElYes ONO
Jl .S'= 22Date
-
ay itch e18natwe, i cerLfy that ttda report 13 acucrata and compre:o to ft best of my kn7MOdgo.
Permittoo Certification
Permittee: %Holt Lake
/Golf & R,�yec.. CL DBA J�ston Co. Country Club
Signing Offlciai: l,C,J�` l '� ` ,j'S (/
Sig ni ng official's Title: 6—e_,e,,%Phone Number: j�jS3 �r �JtO rc Permit Expiration:
Signature Date
I certify, undar penz!h' of law, than ft doqumanl and aft atlachmarrs ware prepared under my dmc!W or
eocordanc© w1h a system doslanam ad to assthat aquaVW pueennthe al prcpey gathered and ovatuatad ha
sutrmittod. Based an my ImOV of tho poraon Cr persons who marmgo the ayatem, et those persarr3abectNreafor
gnurering iha trdormaUon, the tnfomraltan suhmftlod is, to ft boat of my kmWedga and batlol. tare, aoauato, 0m odmNeto,
aware that them are sigre5 mrd panaliias far submitUre falso tnformallon, Including
the pas slb6 iy of {hxrs midtern
knowing vfo:at CM
Malt Original and Two Copies to:
Division of Water Resources
inforrnation Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617