WQ0019908_Monitoring - 04-2021_20220328

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-Permit No.: WQ0019908 Facility -Name: Johnston County Country Club County: Johnston Month: ( Year: ZX)L /
PPI: 001 Flow Measuring Point: QIrtluent f�Efnuent ONO now generated Parameter Monitoring Point: (]Influent ['Arth,ent EjGrotmdwater Lowering Osurface 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? 7omptlant ❑llon-Compllant
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
Permittea Certification
ORC: j�j
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Permittee: Holt Lake & Rec. LL(�C DBA Joh ston Co. Country Club
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Signing Official. C (" , '� t C " o`' S 17
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Certification No.. NA
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Grade: NA Phone Number: 3J? 1r' � [ I
Signing Official's Title: e ..Has
the ORC changed since t previous NDMR? ❑Yes [XNo
Phone Number: — ! ✓ �� �! Y Permit Expiration:
Sig ture Date
Signature Date
By this signature, I certify that this report Is accurrate and complete to the best of my knowledge.
]certify. under penally of law, that this document and all attachments were prepared under my difectlon or supervision In
accordance with a system designed to assure that all qualified personnel properly gathered and evaluated the Information
submitted. Based on my bAulry of the person or persons who manage the system, or 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 significard penalties for submitting false information, including the possibility of fires and Imprisonment for
knowing vlolations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617