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i ~_ <br />ss~ <br />eeeee. <br />~ °' <br />ti <br />_~ <br />7EE NAME/ADDRESS pudil. fsWryNs/(xaNw dDyFu.p NATION ~•~ SCRAROEEH MATICN'SYSY[M./NP(S~SI z- F - ---->r"+:i:;=-. ~ - FD~b~1LtPPFQYVd. <br />nlao~-`v~er?T~nMrrnel~r_ocenc4~num ~' . _ - -c-.-...- - ___ __ __ ..,., <br />---knY~L~noah coAt conPArx <br />ssROAG~ID~ ;+1NN,, N S S PORTALS <br />~, P.G. 9u.x. 14lL] <br />°' PALiSAD,' CU 8151'D <br />y <br />ION <br />ii JUHh A. ^.C'NAt3, F6h'::IllErY' <br />~ PERMIT NUMBER ~ ' DISCHMGE NUMBER ~ <br />MONITORING PERIOD <br />YEAR MO DAV YEAR MO DAV <br />FROM TO <br />!IO-111 112-231 11I-251 126-271 115-291 !36911 <br />(5UHR MCA <br />F - FISAL <br />MINOR <br />-se _'a "„ <br />Y#~ NO DISCHB~$~r <br />NOTE: Reed Inetructiorr before eompletinp thu form. <br />-~--'--~= - ~~AHAMETER _ . 13 Grd Onhl QUANTITY OC~OAQING . - <br />~ k f¢!d Onhl QUANTITY OR CO_ NCENTRATION <br />~ - <br />~ ~ DF <br />~ FREQUENCY <br />~ <br />~ <br /> 146- <br />53 151- .. !38-15 - 1~6=5~ <br />I5Y6/ '~ --DF- ~- <br />T <br />l32-371 <br />AVERAGE <br />:_ MAXIMUM <br />UNFTS <br />~ MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX <br />!at-a]1 ,W,LLyyB <br />/6I-681 YPE <br />(6&701 <br />H SAMPLE P#APP#' PPP### #aa P+G'.~ ( i~) I <br /> <br />MEASUREMENT <br />,(~ <br />1' <br />7 i <br /> 1 I <br />U4UU Z 0 O ; .::;P.ERMIT:.:j:-;:;: <br /> <br />RE <br />~yE <br />EN :.. ##P ~#~. <br /> <br />~ #0~ ?@I?' <br />:. <br />~ #4# •5 " <br />aW.#i##.. q;Q .: . <br /> <br />: <br />:: <br />' <br />~ <br /> <br /> <br />%2Y <br /> <br /> <br />rSITU <br />L:FFLUErT CROSS YAI,U Q <br />M <br />yT~ :: <br />.pt ...~:..:: ~::~:~..:~:+ ..:.;ry ~:'".- •:: <br />::.? r.~ ##R# ~: r~tssrlLn .: ~.~ ~~~ - ~ ~: ~;:~~..•.: ::: <br />~.~:d A. <br />i; <br />.E :1l <br />.iOLIDSA TOTAL SAMPL :~ ' PP4A1##' `'.{~fillrfpl~¢, <br />M <br />~t a##a## <br />~ - <br />~ 5 <br />L Sq) <br />'~ <br />I/ - <br />~U~PBNUE7 MEASUREMENT ,, : <br />. . <br />: ) ~ ~, <br /> ...:. <br />,- <br />US30 1 0 U PERMIT ''' <br />i,R101 <br /> <br /> <br /> <br />.. <br /> <br />:,:. <br />`' <br />. <br />. <br />. . <br />+ <br /> <br /> <br /> <br />aaP <br /> <br /> <br /> <br />.::~:~L4?l+Al?OF'i <br /> <br /> <br /> <br />35 <br /> <br /> <br /> <br />~ ::'.. :::',.:..:: <br /> <br /> <br />' <br /> <br /> <br /> <br />` <br />CE/ <br />~I <br /> <br /> <br /> <br />RA@ <br /> <br />c <br />'Fk'LUErT G SS YnLC <br />REQUIREMENT:: <:..,.,_.... <br />:':i'. ~. :. . <br />..;~:,..,<.:.:..., <br />. <br />~. .~~....,..:.:~ <br />:..:~,~..:: `.:_::: <br />,.......».. <br /> <br /> <br />yFCM <br />~ ~•. -r. •,.:; .::.:. . <br />`" '.::.-' <br /> <br />300 <br /> <br />Al `^~, •...:..: <br /> <br />RG . <br /> <br />```; , <br />, <br />,:.. <br />:: <br />H <br />LRUaa ? 1 '' SAMPLE #####? >~~#### #Oa0## <br />{ Iq) <br />!~ <br />(A~ f'~) MEASUREMENT ~'1 <br />y ~ <br />1UU S 1.: c Q ~ U PERMIT Gt=t:A#-R# ':: . SC#4~G+"'. ##t .: ~ ("r ill#tO~aR 3. S <br />~ .. ~F'ii:G::~.;<::~..~ ~::~ ~ DI~EI iR/LS <br />'FFLL{ErT ~tB05S VALU 'REQUIREMENT PAP j.dDA. ~iFG .AT 'i' !4X rG/L %`. $OR <br />7IL N C SASE SAMPLE ~:G GL~':# :;'43## ###### <br />{ Iq) <br />I <br /> MEASUREMENT ~I ~ /~ N~ F} ~fi N i F r I i ,j <br />)3~$1 1 :.0 U PERMIT P####a,. '?##~#XA ##G P'41tIC4Sl RE FORT. ]~Q `.r ; or7raN ~RI13 <br />'FFLU6rT GROSS VnL'Jf ,REQUIREMENT .. #*:;=# 30EA •:AYC Ets7:n1X RG L G N <br />LUY, IN CONDUIT (ld SAMPLE ( Oj) ###t+#~ t,.;#### #R##P# I <br />r:EHL TREAT lIENT !'LA VT MEASUREMENT Qai~l (? -G 1 L <br />OUSU 1 D C PERMIT .. NRPfIiY:T iiEPQa~T.. >x:~;0ia3 ~>~~4~? ;?9$>Q#~#..r ##IF ;.' S.&KLY rSTAN <br />FPLUENT GROSS VALU .REQU.IREMENT 3UDA: AVG DAI).I.11li : GD 1':.:.:::::.::'a:.: ..: : ;.-:.. a#~#• <br />i LI ~ TOTAL SAMPLE ##P:#.~ Par###.-- #t41o3# ++ <br />( Iq! ' <br />ISSOLYED MEASUREMENT ~ ~ C, ~'v7 ~, ~- i` , ; L, <br />lU195 1 U D PERMIT' #~r#4Pr a#aaa~ #.~ Papt~~4#:. REFOHT;': R$FOET '[HLY tR116 <br />-e FLUENT GROSS VALU .REQUIREMENT - ~ ~ PP# ~ .: A3H.~IFSIG :~QRTE nAY RG/L <br />~ZL GR SE SAMPLE #PP#:P { 9µ) Oaaaan tltiilaan aC#?#sz - <br />I S U A L MEASUREMENT ~~ 4~ <br />- 1 <br />- <br />4U66 I U 0 PERMIT <br />.. PEa#os3 ::.: <br />.:. :.RL.P#k$T : <br />... ES=1 ":L:P#'+Pa# ;' e>14i1'4:o;.: `::,:~##%1:8.fF AIT# bhL <br /> <br />~ " Y SUA <br /> <br />L <br />L <br />~t'FLUEN? GROSS VALUE REQUIREMENT. . <br />NAME/f RLE PRINCIPAL EXECUTNE OFFICER I eERTI FY UNDER PENN.TV OF uW TNAT I NAVE PERSONALLY E%AMINFO AND TELEPHONE DATE <br /> AM FA MILIM WITN THE IMFOflMATION SUBMITTED NEREIN; AND BASED ON <br /> <br />' MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR <br />E _~ ~ <br />- J <br />` I OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />TflUE. ACCURATE AND COM0.ETE. 1 AM AWARE THAT THERE NiE <br />SGNIFCIWT PENALTIES FOR SUBMITTING FKSE INFORMATON <br />INCLUDING <br />/`. <br />' " / <br /> <br />( <br /> <br />- <br />' . , <br />THE POSSIBILITY OF RNE AND IMPPoSONMENT <br />SEE 1B U <br />S <br />C <br />! 1001 AND ]] ~ <br />J G ~r~ <br />~!~ <br />,' ~ I <br />~, p r` . <br />. <br />. <br />. / 810NATURE OF PRINGPAL EXECIlTNE ' <br />~ ~ ~ <br /> <br />TYPED OR PRINTED U.S.C. ! 1 ]10. lPrrM.. rides N.r mAm. wrY iroA.d. Awa ue ro F IO,000 <br />.ndonl..:...n MA+4a+rr+r a/anrwn enAra.WaYArA/ <br />OFFICER OR AUTHOR2ED AGENT <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAV <br />COMMENTS AND EAPLANA710N OF ANY VIOLA I IONS lRetersnce e// etteenmenfs ne7el <br />tHIS OUTFALL IS NOT L'LIGIBLk: FOR EidnPTIONS PROA TOTAL SUSFENDEC SOLI CS (255), OCTAL IRON AND/0& <br />;,.,TTLEABLE SOLIDS LIk1ITATIONs - 566 I.A.2. <br />[4 <br />EPA Fwm 3320-1 109-961 Previous editions mey he used. (REPLACES EPA FORM TAO WHICH MAY NOT BE USED.1 ,U }U.3 Z 1 / 9 R C Z 2 j -1 1 S 6 FAGS 1 OF <br />