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-~ pERMITTEE NAME/ADDRESSQ~ifrdiry NaWL«+nan dDlCrrwn) <br />NAME pONDERHORK CORL C08PANY <br />ADDRESSR0AD5IDF. ~Iu};+ h , PORTALS <br />P.O. bOX 7.130 <br />PALISADE <br />CO d152o <br />FACILITY <br />LOCATION <br />.iTTA: JGctr1 A. :IC.~'Ar?, ~tF.'S.DENT <br />1.._ ~_ ~_:~ roved. qp;, <br />7=rep -.- -/sI - P.D1t~D 4 1"Q 60T'Y!' !lI a ~~-Qo*~^31 sa ~ - <br />000 7146 ~ { 006 <br />(SDE9 iC} ~~`~~~ <br />PERMIT NUMBER DISCHARGE NUMBER F- F I! A L <br />MONITORING PERIOD HIyOFt <br />YEAR MO DAY YEAR MO DAV <br />FROM U U U TO ~ _ r"--'•~ NO DI SCHARG@ ~~ E''^'0 <br />rzaz/l rzs-z3i ri475i r7s-77r ue-7s~ r3o-311 1 NOTE: Reed Inetructlaa belon completlnp this form. <br />PARAMETER l3 Grd Onlyl OUANTITY OR LOADING. !4 Grd Onlyl QUANTITY OR CONCENTRATION Np, NIEDUENCY SAMPLE <br /> lIG531 !546!1 !38-15 !1653 151-5I1 EX TYPE <br />l37-371 ANµY515 <br /> AVERAGE MAXIMUM ~ UNITS MINIMUM AVERAGE MAXIMUM UNITS N7-eel 164681 169-701 <br />' IL AND GdEASE SAMPLE ~'s:-C ~ ~ ( 9q} rp#~I##tQ 40AL## .t33+15n~ <br />V I'r U A L MEASUREMENT <br />ti4Ubb 1 0 U PERMIT r pr»>Killi: @~. 1'TRT ES=1 tc!b#4#.#. ptp;tp#~I:.. '.ta~7Q701?~97e:.: QOlti t`.riklY ~S@AL <br />EFFLU@NT GROSS VALUE FlEnu1REMEN7 IR$'><'. If]17(: NO=0 '.. : ~. #O#~ '~`::: ` <br /> SAMPLE <br />~ <br />- - ` :. r <br />+~%~ <br /> MEASUREMENT ~ <br />~ ~ . <br /> PERMIT .. .. ..... ....:.. ~~. .: -~ <br />~ , <br />~-.., <br />.~ . ..~~5 <br />...,., <br />. <br /> •REQUIREMENT ~ ~ . .. <br />,.. ,. . : <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~ ~ ~ .~ ~ ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ ~ .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> .PERMIT <br />~ ~ <br />~ <br />~ ~ ,.. <br /> REQUIREMENT ~.I <br />' <br /> SAMPLE ~ • - ~ t <br /> MEASUREMENT '~ <br /> PERMIT <br /> REOUIREMENT: ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT, ~ ~ ~ . <br /> REQUI.RENIENT' <br />NAMElTITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR VATH THE INFO lAW TNAT I NAVE PERSONALLY EXAMINED AND <br />RMATION SUBMITTED HEREIN; AND BASED ON TELEPHONE DATE <br />/ MY INQUIRY OF TNOSE INDIVIDUKS IMMEDIATELY RESPONSIBLE FOR <br />J E S <br />VCIL <br />^/O OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS ` <br /> TRUE, ACCUMTE AND COMPLETE. I AM AWARE TNAT THERE ARE <br />TIES FOR St/BMITTING fAL3E INFORMATION <br />INCLUDING <br />SIGNIRCANT PENN G <br />` <br /> , <br />. ~ a~ <br /> THE POSSIBILITY OF FINE AND IMPW SONMENT. SEE 1B U.S.C. f 1pD1 AND 33 <br />BIONATURE OF PRINdPAL E%EDUTWE y Q <br /> U.S.C. 1 13te. fFlturle++uMr IMw .aror.+m.v YrcAM+ hN• Ie ro 110,000 <br />TYPED OR PRINTED w>nr+inun ireriwmrnW Mn+wn ewlater+rM6 yArA/ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Relerence s!l sttsehmenu here/ <br />;ih'PTL@AULE SOLIDS LIRIT5 APPLIES ONLY IF <=1DYR,24HR PXe.CIPI4ATION FVENt Z~ CLAIl:kD. PERMITTSE Fi65 <br />~URUEN OF PROOF WHEN REQUESTING RELIEF F3rJh SETTLEABLE SOLIDS PRIl1ARY LII!ITATIODS. <br />EPA Fpm 3320-1 108-951 Previous editions mey be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE UBED.1 0 0444 / 9 9 C 2 2 3' 12 5 6 PAGE `OF <br />