WQ0019908_Monitoring - 08-2021_20220328

NI-ORM: NDMR 19-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s) Certified Laboratories
NA
Name: NA Name: '
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 174Lompfiant LjNon{bmpliant
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
artinnfel taken Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: jjt,�� 5 �,e-)
Permittee; Holt Lake/Golf & Rec. LLC DBA/Johnston Co. Country Club
1"(
Signing Official: t s ( /'v
Certification No.. NA
Grade: NA Phone Number: 3j!°� 1 r
Signing Official's Title:
Has the ORC changed since !ke previous NDMR? ❑yam `f"'e
Phone Number: — q, �/ �[ Permit Expiration:
Sig ture Date
Signature Dale
By this signature, I certify that this report Is accurrate and complete to the best of my knowledge.
I tort fy, 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 qualNied personnel properly gathered end evaluated the Information
submitted. Based on my inqulry 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 beliof, truo, accurate, and complete. 1 am
aware that there are sigm5cani pena;iies 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