WQ0019908_Monitoring - 12-2020_20220328

FORM: NDMR 10-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Page of
Sampling Person(s) Certified Laboratories
Name: NA Namo: NA
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 7c rnpliant QNonCompliant
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
Permittee Certification
ORC: J,i C �,p�
keGolf & Rec. LL%�C DBA J ston Co. Country Club
Permittee: Holt La�J/S
� V
Signing Official: CH17 " m C" �`'S (/h
Certification No.: NA
Grade: NA Phone Number:
�J?1�� [ r
Signing Official's Title:
Has the ORC changed since t previous NDMR?
❑yes 9610
Phone Number: — ! ✓ �� �( Permit Expiration:
Sig ture
Date
Signature Date
By this signature, I certify that thJs report Is accurrate and complete to the best of my knowledge.
I certify, under penally of law, that this document and all attachments were preparod under my direction or supervision In
accordance with a system designed to assure that all qualified personnel properly gathered and evaluated the informalien
submitted. Based on my inquiry 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 beliof, true, accurate, and complete. I am
aware that there are sigmfinanl penalties for submitting false information, including the possib0ity of fins and imprisonment for
knowing vlotatlons.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617