WQ0019908_Monitoring - 03-2021_20220328

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? compliant LNon-Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in comp'iance. 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
Permittoe Certification
ORC: �Vx�,Qi��Permittee:
Holt LakeGolf & Rec. LLC DBA Joh ston Co. Country Club
Official: /�/1�t " CD,`'S
Certification No.: NA
Signing "
g g (` r6e,,e,­.
Grade: NA Phone Number: �J?� [ r
Signing Official's Title:
Has the ORC changed since It previous NDMR? Dyes [Xrlo
Phone Number: q1 i; _ �j q, �16 � Permit Expiration:
Sig tune Date
Signature Date
By lhls 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 allachmenls were prepared under my direcllon or supervision In
accordance with a system designed to assure that all qualNied personnel properly gathered and evaluated the information
submitted. Based on my Inquiry of the purson or persons who manage the system, br those persons dtreotly responsible for
gathering the Information, fto Information submitted is, to the best of my knowedge and ballot, true, accurate, and complete. 1 am
aware that there are slgn3ficard penalties for submitting fatso information, Including fhxe possibility of fnes 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