WQ0019908_Monitoring - 05-2021_20220328

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Permit No.: W00019908 Facility -Name: Johnston County Country Club County: Johnston Month: f4 Year: 777
PPI: 001 Flow Measuring Point: ❑Influent Effluent [:]No Now generated Parameter Monitoring Point: ❑Influent Effluent ❑Groundwater Lowering ❑Surface Water
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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? 91L0
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pliant ❑Noncomptlant
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:
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Permittee: Holt Lake Golf & Rec. LL%�C DBA Joh ston Co. Country Club
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Signing Official: C fl (5 C " �`'� 17
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Certification No.: NA
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Grade: NA Phone Number: 337 - { �r' (
Signing Official's Title:
Has the ORC changed since t previous NDMR? Dyes 9610
Phone Number: —1 �,. p �( Permit Expiration:
Sig ture Date
Signature Date
By this signature, I certify that this report is accurrato and complete to the best of my knowledge.
I certify, under penally of law, that this document and all attachments were prepared under my directlon 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, br those persons directly responsibie for
gathering the Information, the information submitted Is, to the best of my knowedge, and belief, true, accurate, and complete. I am
aware that there are significant penaS ies for subm tting false information, trrcluding the possibility of flees and imprisonment for
knowing violations.
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Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617