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PlRMITt[! NAM[IADO R!{{ (IntIMJt
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<br />1~(. ~h COflPAHY, THE
<br />NAME------------- - - - --
<br />AoaREBtIGRASSY GAP CLINE ___
<br />ONE EASY lIILYAUREE STREET y
<br />JAYzSVILLE YI S3S4'T~
<br />-wcrurr_
<br />LOCATION __
<br />ATTN: RAdLN RABUCE, VICE PRESIDENT
<br />NATIONAL RO LLU TAMT OIICN ARC[ [LIMINATIOM {Y ST[M /NPDESI
<br />DISCHARGE MONITORING REPORT /DMRI
<br />1.16 17-I9
<br />COG85 23 0 4 A
<br />PERMIT NUMBER DIECHARC[nVM.[w
<br />MONITORING PERIOD
<br />Y Y
<br />FROM TO
<br />l10~1l1 /27.13) lSI.15/ (I - l 118 l I !/
<br />tlINOH Forrr~~App~~roved.
<br />(SUBR NY)OMBRC1.~2a40-0004.
<br />P - FI BALApproval expires 6.30.91.
<br />PZT it DSCBRG TO GRASSY CREEK
<br />### BO DISCHARGE ~~~ ### FINAL
<br />NOTE: RBBd instruction before eomplatinp thi{ form.
<br /> (J Card Only) QUANTITY OR LOADING (J Card Only) OU ALITY OR CONCENTq ATION FR EOU ENCY BAM PLE
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<br /> MEASUREMENT
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<br />RRU TREdTflENT PLANT MEASUREMENT
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<br /> SAMPLE
<br />ISDAL MEASUREMENT
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CCRTIFV uND[R KCNALTV
<br />oi LAw THAT I NAVE KERSONALLV E%AMIN[O
<br />ANO {M i{MILIAR wITH THE INipRMAT10N SUBMITTED NCREIN AND BASED TELEPHONE D A T E
<br /> ON MY INOIIIRY OE THOrE INdVIOUALS IMMEdATELY RCSPONSIBLE F //
<br />
<br />
<br />
<br />arla Rabuck
<br />
<br />OBTAINING THE INidiMATIOV. I BCLIEVE TNC SUBMITCD INFORMIr
<br />IS TRUE ACCURATC AND CONKER[ r AM 4WMC THRT THERE ARC
<br />NIirC1NT PENAETIE$ FOR SVB/IITTING FALSE INFORMATION INCEUdNG
<br />'`((
<br />/I
<br />l~[~--`~
<br />Vlce President THE Ko551BrLlTr of FINE AND IMKRISONMENT 5[[ IB u5C I laol AND a NATURE OF RINCIPAL E%ECUTIVE 608 754-2291 93 D8 26
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<br />O OFFICER OR AUTHORIZED AGEN NUMBER YEAR MO DAY
<br />COMMENT ANO EXPLANATION OF ANY VIOLATIONS (Rrlrrmrr all mmahmtnlF hrrt)
<br />SETTLEABLE SOLIDS LIflIT APPLIES OtlLY IF <= 10-YR, 24-HR PRECIP EYEBT IS CLAZHBD. IF CLAIfl APPROYSD BY
<br />YOCD, TSS b IRON LIlIITS PILL NOT BE APPLIED TO REPORTED tlEASURHtlEBlS--SBE I.B.lA, PG 4 6RD I.B.1D, PG 6.
<br />Form 20.1 (REV. ) Beditronsmaybeused. IwEPLwc[{EPw FORM T-.o wNICHMAr Nor BE u{cD.) 000 60/92 1016-16 35 PAD[ 1 DF
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