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PERMITTEE NAME/ADDRESS (1riJ~Frlery NrWls•um IJD:Qn.n,)
<br />NAME PU~UC}:klldr: C,UA:, C~iPf,\Y
<br />ADDRESS kUAJ., l: ': h..• .. ,i rOkTA..-.
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<br />FACILITY
<br />LOCATION
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<br />NATIONAL Ad1.T.qq}Y11NTDIBCHMOE ELIMINATON SYSTEM INPDESf
<br />:DISC4fARGE MONITORING REPORT IOMRI
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<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAV
<br />FROM / U4 'v 1 TO ,l U ;U
<br />(16111 /11-131 114151 116-171 118-191 !3631/
<br />- Form Approved.
<br />POND R id COLOHID~~°Y~oao-oooa
<br />($UBA M(.~ PProvel e`plres 05.31-98
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<br />F' - F'I SAL
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<br />NOTE: Reed Inetruetioru bslors complatinp thin form.
<br />PARAMETER !3 Grd Onlyl QUANTITY OR LOADING 14 Grd Onlyl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
<br /> 115-531 !545/1 13851 (46-53 !545/1 QF
<br />l31-371 EX
<br />MKY$IS 7yPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS l6l.eel (64661 !69701
<br />• SAMPLE
<br />MEASUREMENT C'4'i,r :Y ri 4:r: >:: >ry ] /
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<br />~u}J`.' i U 0 PERMIT
<br />~ ?:=:I~k¢eSrx~ #tiLt;Yx`-Lti • r,:~,I 6.5 Ip44t10>5 ~•0 IEEYLY [NS1:'U
<br />'-F'i..Utt.T Gn0'SS VALUE RE¢UINEMEN7 4;1F{< !LLNIMU?F ~ RAYYq^i+l~ 3U
<br />J:.I U:i~ fJTAL SAMPLE C++4rAG4 ~3;FCM7 4glpgA,, ~ Iy)
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<br />:~S3U 1 U U PERMIT. ?40St4F,t :. #ts?#AilO fe00 4Ar?0»tA ~~ 'f {} lFCI./ :AA L+
<br />'F:..Ur,hl Gkuti, YALUF. ;REQUIREMENT ~y0~k
<br />3170A AY
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<br /> MEASUREMENT
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<br /> MEASUREMENT
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<br />~.vL US, 'IU ~ SAMPLE ~:+7[=:: ;:=s t=+Jfi K: fF4 rir~e;:q;tin ( I9)
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDER PENALTY OF uW THAT I HAVE PERSONALLY E%AMINED MD ;
<br />/ TELEPHONE DATE
<br /> AM FA MILIM WITH THE INFORMATION SUBMITTED HEREIN MD BASED ON'
<br />I MY INQUIRY OF THOSE INDINDUILL9 IMMEDIATELY gE5PON51B
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<br />TRUE. AQCIIMTE MD COMPLETE. I AM AWARE THAT THERE ME
<br />SIGNIFICMT PENKTIFS FOR SUBMITTING FALSE INFORMATON
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS IFsference d/attachments here)
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<br />Epp Form 3320-1 108.95) Previous etlitione mey be used. /REPLACES EPA FORM T~0 WNICN MAY NOT BE USED.1 U U 517 / ~ R (2 2 .3 - 1 ~ 5 G PAGE I OF
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