WQ0019908_Monitoring - 10-2021_20220328

FORM: NDMR 10-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Page of
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? r%compliant ❑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
actions) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: C, )
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Permittee: Lake Golf & Rec. LLC DBA J h ston Co. Country Club
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/H`�olt
Signing Official: 1... HgO t C��`'S (I
Certification Not.:/„ NA
Grade: NA Phone Number: [ f
Signing Official's Title: 6e"e,,,Has
the ORC changed since t previous NDMR7 Dyes[(fo
Phone Number: — q,. ��� �( Permit Expiration:
Sig ture Date
Signature Date
By 1h1s signature, I certify that this report Is accurrate and complete to the best of my knowledge.
I certify, under penally 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 quallfled personnel properly gathered and evaluated the Information
submitted. Based on my imulry of the person or persons who manage the system, br 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 slgnifican: penalties for submitting false information, including ttie possibility of Rnes and Imprisonment for
knowing vWalions.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617