WQ0019908_Monitoring - 06-2021_20220328

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Permit No.: W00019908 Facility -Name: Johnston County Country Club County: Johnston Month: �� e Year: 20 Z
PPI: 001 -- Measuring Point: ❑IMluent (Effluent ❑Plo now generated Parameter Monitoring Point: ❑Influent . Effluent ❑Groundwater lowering ❑Surface Water
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Sampling Type:
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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? 91Comprant ❑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
action(s) taken, Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: j(,� S1�d_,iA )
Permittee: Holt Lake Golf & Rec. LLC DBA Joh ston Co. Country Club
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Signing Official: C /"/ 15 M cDo,,S 17
Certification No.: NA
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Grade: NA Phone Number: 3310 [ t }
Signing Official's Title: , t } VHas
the ORC changed since t previous NDMR? ❑Yes 0,10
Phone Number: —�3 q, Permit Expiration:
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Slg tune Date
Signature Dale
By Ihls 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 a!I allachmems were prepared under my direction or supervision In
accordance with a system designed to assure that ali qualified personnel properly gathered and evaluated the information
submitted. Based on my "ulry of the person or persons who manage the system, br those persons d!ractly 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 ere signifitcan! penaflies for submitting false information, ireuding 6e 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