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PERMITTEE NAME/ADDRESS Nn~a. FwreryNw/Leculen UDlO..nq -~' <br />NAME- POiIDdAt10kY COAL CUAPAYY ~--~! <br />ADDRESS ROADSI DE MIdE, d ; S PORTALS <br />P.LI. 60X 14~~ <br />PALISADE CO ;11525 <br />FACILITY <br />LOCATION <br />r.'TYN: JOHa A• 1".CHA?. P.i~':;II:ENT <br />DISCHMGE NUMBER <br />MONITORING PERIOD <br />"YEAR MO DAV YEAR MO DAV <br />FROM V TO <br />rJ11J11 IJJJ31 tlLJFI 02J)I UR-0RI /3Q311 <br />-- --~~-'- - -FOrRi-Approved. ,Y~ <br />asy>•-to-~~~f X ~g~QO~~~q ";1,11 <br />(5U6R YC) o e eL~4~~Q531~8 <br />F - PIhAL <br />MIYOR <br />i <br />~~~ NO DISCxAAC6 u''r` <br />NOTE: Rssd Instructions bslor+ complstlnp this form. <br />~~ °-~ PARAMETER l3 Are OnlYl QUANTITY OR LOADING (e Grd Only/ -IlUANTITy OR~QfICRN'I~AUQN @- FREquENCY SA~d <br /> Is6-531 15a-57) !3B-r51 !46531 f5I-611 EX TYPE <br />I3Z-371 MALYyS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE .MAXIMUM UNITS /ez-ssl (5s-5B) 164701 <br />LC U S'fATAE 48xk AC SAMPLE R00~:`.,',: :~;:aaa: alaa>aaa #l9f00 <br />( 23) <br />I <br />CExIODAPHAIA. MEASUREMENT ~ IOD {} /9!' ~sh <br /> <br />rAM3H 1 0 U <br />;:,:.PEgMIr":: <br />~aaaa0 <br />~xy!ti;p?G>t: <br />0%IG . <br />34#i.. <br />Afld: <br />"" <br />: a~p:444d <br />OL!.t:#u# :: <br />ER- • <br />S$ZY" <br />:BAS . <br />cFFLUe:h'r GROSS YALU REQUIREMENT, Oaaa . <br />. <br />RR, RAT;"$.$' . <br /> <br />:.:,~U SYITRE 96NR AC <br />SAMPLE <br />rlk;F~,^^•:: <br />#4400 <br />0~?Md4AI <br />O0#4016 <br />~ 23) <br />~ Q <br /> <br />k'IM'~PHALBS <br />MEASUREMENT <br />>.~O'0 <br /> <br />' <br />~ <br />Q/) ~ I\ <br /> <br />fhYSC 1 0 0 <br />PE~iM1T :: <br />~«S+f.?fk# .4.w.'.E#. .Sl ~.': <br />~ >tla4 ,...i~.:.~., <br />4 <br />~a0 .`...:..; <br />~!~:~!:":;: :::::~..:~~~~?.. ,. . <br />~~ " :..6SL;" iR1~8 <br />.FFLUENS GYO~$ MILD REQj~IRE <br />MEN7 . <br />. . <br />. . <br />- SAMPLE ~ ~ ~ - <br /> <br />' MEASUREMENT ~ S ~" <br />~:~ ~ PERMIT .~ ~.. .~: ... <br />. ~ .. , . <br />.. <br />.. <br />l( .. ":REQUIREMENT , :~ ~ +~ <br />"~~ SAMPLE - " <br /> MEASUREMENT <br />..;E PERMIT ~ ~ ~ <br />~ ~ ~ - .. <br />~ ~ ., .. <br />~Y :REQUIREMENT " <br /> SAMPLE <br />' MEASUREMENT <br /> _...' :PERMIT : ~ .: .. ~ ..:. <br /> .REQUIREMENT <br />. . <br />~~ - " . r:. :r .... ' .-~ ~ ~ s°.::. :~. .. q.:!'~....~.~: '"': <br /> SAMPLE <br /> MEASUREMENT •. <br /> :~ PERMIT ~ ~ ~ ~ "" <br /> REQUIREMENT <br />~ <br />' SAMPLE - - - - - ~ " <br /> MEASUREMENT <br /> :::..PERMIT ... ~ : ~. ~ .:. ". ... . <br /> 'REQUIREMENT ~ ~ ~ "" "" <br />NAME/TRI.E PRINCIPAL EXECUTNE OFFICER I cl[RnFV uNOER PENALTY of <br />AM FAMILIM WITH THE INFO uw THAT I HAVE PERSONALLr E%AMINED AND <br />RMATION SUBMITTED HEREIN; MD BASFD OM TELEPHONE DATE <br />~ <br />E ':. 1 I'•V C~-( O MY INQUIRY OF THOSE INDINDUAl3 IMMEDIATELY RESPONSIBLE FOR <br />BTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />' <br /> TRUE, ACCURATE AND COM0.FTE. 1 AM AWME THAT THERE ME <br />NIRCANT PENALTIES FOR SUBMITTMO FALSE INFORMATION <br />INCLUDING <br />A <br />I <br />n <br />~/I ~ N-}- , <br />G <br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 1B U.S.C. 1 1001 MD 3] <br />610NATU OF MIINCIPAL EXECUTNE 7e /r,l <br />4S" ( <br />> 1 /J I <br />I ~ r) ~~ <br /> us.c. f tsts. nwu.• anew swr mvro. In.r .l./vw nl.. m ro t 10,000 AREA <br />,_, TYPED OR PRINTED wqw muirwninpio.lwrt oFentwwnsmana. rgsyra/ OFFICER OII AUTNORIZED AGENT CODE NUMBER YEAR MO DAY <br />sw <br />~:~ <br />~ ~. <br />f. a - <br />ra <br />.,. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS fRs/erencs ell sttechmsnrs hers) <br />52E PRAY I. B.4 FOR DETAILS OP TESY PRJCF.DUWE. dPT LOMEST DILUTION (~FFFLUFdT) WHICH IS LETHAL i0 50~ OF <br />,ES'r OAGAYISMS (LC50) 6 ATTACH ACUTE TOYICITY TEST REPORT FORM, TO DMA. COPIES CF ALL INFO MUST EE SENT <br />T) F DL'DN T c" f f m c rn T m n n n ' <br />EPA Fam 3320-1 108-951 Previous editions mey be used. IR PLAC EPA F M TAO WH CH AY T BE D.1 0 0 301 ~ 9 R C 2 2 3 -12 5 L P 1 OF' ' <br />,~ <br />