WQ0019908_Monitoring - 11-2020_20220328

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? 9"omp5ant LuNon•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
artinnlsl taken. Attach additional sheets if necessary,
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: jjtl� S11� - �
Permittee: Holt Lake & Rec. LLC DBA Joh ston Co. Country Club
/Golf
Signing Official: ` " CDo`'S 17
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Certification No.. NA
g g
Grade: NA Phone Number: 33�- ! 5/rY,5,& 5
Signing Official's Title: e, Mc-l6)v
Has the ORC changed since t previous NDMR? ❑yes `tN.
Phone Number: —ll qr /�p �( Permit Expiration:
Z�A��z -
Sig tore Date
Signature Date
By this signature, I certify that this report Is accurrate and complete to the best of my knowledge.
I certify, under penalty of taw, that this document and all attachments were prepared under my direction or supervision In
accordance with a system designed to assure that all qualifled 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 lho best of my knowledge and belief, true, accurale, and complete. 1 am
aware that there are significant penatlies for submitting fa:so information, inc:uding the possibility of fines and Imprisonment for
knovring violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617