|
PERMITTEE NAME/ADDRESS P+d/L FsWryNr/laeno. I/Dis null NATIONAL POLLUTMT DISCHMGE ELIMINATION SYSTEM (NPDES/ Form Approved.
<br />NAME
<br />"
<br />, _ _ - l RECEIVED DISCHARGE MONITORING REPORT /OMR/
<br />l7-161 I7-19! _ ~ ., OMB No.~2040-0004
<br />'
<br />,
<br />a r `O
<br />~ .
<br />..
<br />_
<br />. ~APProvel:e$pires OS-31-98
<br />ADDRESS ~: J;. L. _ ' : 0 7 .
<br />..
<br />~ (I ~ -
<br />
<br />:°;°
<br />.::~; APR
<br />0520 PERMIT NUMBER DISCNMGE NUMBER /-
<br />_ .
<br /> 02
<br />r J- I ~ ~ ~.t - ~ ~ MONITORING PERIOD ~' ~
<br />FAaLm
<br />.. T
<br />•. \- .. J l~
<br />L -.
<br />• ~ - ~ •- ° DIVISI00
<br />f YEAR MO DAY YEAR MO DAY
<br />LocATIDN o
<br />Minerals d GeololfjRDM 7 .= ~~ , I ro , ~ - t- ; r ~ ~ - I -~' I
<br />~
<br />
<br />I /:: ~, ,y ~ ., _ ]
<br />~ li . L ,!~ _
<br />,~
<br />!76771 l72-231 111-75/ 178771 129-191 !3431/ 1 ~~..
<br />NOTE: Reed Inetructloru befon•eomplatlDp Thie form.
<br />PARAMETER (3 Grd only! QUANTITY OR LOADING I< Card On1Yl QUANTITY OR CONCENTRATION Np, FREGUFNCr gAMPLE
<br /> l<5-531 /5461 138-151 !4653 !54611 EX GF
<br />/31-37/ Mlursls TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 61.691 (6465) 169-7D)
<br />'+;~ SAMPLE . ~ -
<br /> MEASUREMENT t
<br />V'! .1 ~I :I ]- .: ~ PERMIT ..:F': . , P S- . ... :. ~ ° - .... ~_ :
<br />U "
<br />I "
<br />
<br />~ 1~ - ~ I
<br />REQUIREMENT J ,
<br />_ ..
<br />-
<br />_
<br />~~6=U::Ir .i .. .i, SAMPLE ~ ~ .,,•. `
<br />,-I
<br /> MEASUREMENT a
<br />11J,4i ~ (' .) ~ PERMIT. :. •. ,, :... r.
<br />~. ...r ..• _,: .....
<br />- r
<br />~
<br />;°~ r: r: ;: {:.
<br />.,< 1; . ,.. ,.
<br />O
<br />5
<br />i
<br />.
<br />.
<br />' REQUIREMENT .. , a .
<br />.
<br />I
<br />J: .( r
<br />_ ~. .. a, .
<br />..S
<br />.; .[ - -
<br />. .....J SAMPLE ') ~ .::rj ...r ':
<br />.... .. ~ ~
<br /> MEASUREMENT '
<br />035,.1 i PERMIT :z/~(e t:; .-. ~.. ~:I; •:t .w ... .•: - f~ ~ 'l' ~I' ~,
<br />", U I.'I . i` _ _ .' t REQUIREMENT
<br />
<br />Y ~ j r
<br />.V ~ ~ -
<br />~'..::•.F I .., r..i _ ~ SAMPLE U?,
<br />~ !C...
<br />L.; ~ I~ ~ MEASUREMENT
<br />]~.ai~ 1 ~ ~ PERMIT ii.'_~i V'. a i:~_": la•~ :: ~:'~;.:; ~. -p>F :fit,' :F ".:: ;:: P: _' •+
<br />, i
<br />_ i :' L G ~ r -, REQUIREMENT . Ii r, i 1 ~ ~ ', i, !..' i , :. Cr) ~
<br />J,:./JS, _a7 •; - SAMPLE .. 2': 3: ~ ~.. .r .t
<br />~ l ~.i ;I L . _ „ MEASUREMENT
<br />/0.77 -. ~ i PERMIT ....
<br />~ :::
<br />- .;
<br />- .:'t :.•. -~` -
<br />r'ti ~ ti :'. _
<br />1 L'
<br />i '
<br />' L U L ~
<br />• REQUIREMENT i. I..p r
<br />_ ~..; J
<br />-. a . .- SAMPLE .. / - ;) ~ . ,-.. .. .
<br />/
<br />~
<br />/ MEASUREMENT
<br />.
<br />~I
<br />L
<br />v : d b .1 ~ '. .` PERMIT ~ .. ., . ~. - _
<br />~ .- ... ~ .. .. . , ... - •' ~
<br />.~ .. f.'I ' ' ~• ~ •. i.
<br />~- 1. U ~ ~ , : 1 ) ; ~_ REQUIREMENT - .r
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT .
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTI FY UNDER PENALTY OF lAW THAT I NAVE PERSONALLY E%AMINED MD TELEPHONE DATE
<br /> AM FA MILIM NATN THE INFORMATION SUBMITTED HEREIN; MD BASED ON
<br />\
<br />I/
<br />1
<br />/ -- MY INOUIflY pF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR
<br />_
<br />„
<br />1 f_;
<br />.
<br />'
<br />• OBTAINING THE INF011MATION, I BELIEVE THE SUBMITTED INFORMATON IS
<br />TRUE. ACCUMTE AND COMPLETE. 1 AM AWME THAT THERE ME
<br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING - __
<br />~/~ / :~ _
<br />/ "'
<br />~~
<br />~ ,
<br />THE POSSIBILITY OF RNE MD IMPRISONMENT
<br />SEE 18 U
<br />S
<br />C
<br />1 1001 MD 9 ~
<br />' ~/ S
<br />" 'r
<br />/
<br />• '
<br />~ 1.". ~~
<br />1
<br />N. .
<br />.
<br />.
<br />.
<br />]
<br />u
<br />B
<br />t
<br />f t]to
<br />P
<br />BY
<br />e
<br />/
<br />d
<br />F
<br />>
<br />1 /
<br />SIONATl1F1E OF PRINCIPAL EXECUTNE I
<br />/' '
<br />1 I
<br />~ ( • 'i ,.. '
<br />1
<br />TYPED OR PRINTED .
<br />.
<br />.
<br />. (
<br />w
<br />r Ia1
<br />.r
<br />nw aaumr nnr
<br />tlNr w ro
<br />10,OD0
<br />z
<br />1.dr
<br />wdllr.+:~I.lrxw+d•Iwlrwan.«Ilerool.ms.ns6y.FZ/ OFFICER OR pUTHORI2ED A0ENT AREA
<br />CODE NUMBER YEAR MO DAY
<br />LiLIINMCry1J XIYV CI,rLIV~I~IIVn yr nl~l vIVLI.IIVI~J InO/OIO/IYO p/OnJI/1//IO//IJ /Itl/tl/
<br />L _ IL. .-1
<br />EPA Form 3320-1 108-951 Previous editions mey be used. (REPLACES EPA FORM 7.40 WHICH MAY NOT BE USED.) PAGE OF
<br />
|