WQ0019908_Monitoring - 07-2021_20220328

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Facility -Name: Johnston County Country Club —7—year: 'ZO
Permit No.:WQ0019908 County. Johnston Month: ___ 1�
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ppl: 001 Flow Measuring Point: Elinfluent OgEmuent []NO flow generated Parameter Monitoring Point: Dinfluent MEffluent ElGr6undwate
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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? IX rnpliant LjNomCompliant
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 fhe non-compliance and describe the corrective
anfinnfsl taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC:
Permittee: Holt Lake Golf & Rec. LLC DBA Joh ston Co. Country Club
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Signing Official: �'�
Certification No.: NA
Grade: NA Phone Number: S3- (�I r
Signing Official's Title: e,-; }�
Has the ORC changed since t previous NDMR? Oyes [t)(fo
Phone Number: -14'3 �� ( M Permit Expiration:
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Sig ture Date
Signature Date
By Ihs signature, I certify that this report Is accurrate and complete to the best of my knowledge.
I certify, under penalty of law, that this document and all attachments were prepared under my directlon or supervision In
accordance with a system designed to assure that al! quali ed personnel properly gathered and evaluated the Information
submitted. Based on my inqutry 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 babel, true, accurate, and complete. I am
aware that there are sign tcani penalties for submnl[ng false information, Including the possibility of fines and Imprisonment for
knowing vitiations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617