WQ0019908_Monitoring - 01-2021_20220328

0 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's tT rnpltant IJhioni Omple.nl:
If the facility is non -compliant, please explain in the space below the reason(s) the fatuity was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
actinnfsl taken. Attach additional sheets if necessary.
Operator In Responsible Charge (ORC) Certificatlon
Permittee Certification
ORC: jjkl ,p )
Permittee: Holt Lake GSolf & Rec. LL%�C DBA Joh ston Co. Country Club
r (
Signing Official: C �f � 1 C " o`'S 17
Sig "
l..�r�I6e,,
Certification No.: NA
g
Grade: NA Phone Number: 3/1°� l r
Signing Official's Title: �r,Has
the ORC changed sincet previous NDMR? ❑Yes ONO
Phone Number: c., -S'3 Lf ,- �( Permit Expiration:
SIg ture 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 attachments were preparod under my direcllon or supervision In
accordance with a system designed to assure that all qualified personnel properly gathered and evaluated the Information
submitted. Based on my Inquiry of the person or persons who manage She 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. 1 am
aware that there are slgrtcan' pena;fies for submitting false information, including the possibllity of fines and Imprisonmenl for
krxN4ng vlotalions.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617