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<br />Pap• vork Reductiolr~ Ac# !'~•c~ ~ '
<br />Puhli r-t-•r! 7; wrdm for rhts collection of mformatioo u e;bimled U; , e ~.If 10 coot, as an
<br />avrragE pr: racn:npr e;,. some minor faciliti~r, to 110 hours as :ui as?rage r .". Ir ,•,mr ma;.•r fa, iliries,
<br />with a weighted avrrag. for major anU minor fa:.itities /~` ' ~ ~. ~ per rs,•u:. ~ :a.l. Ding lime for rev,ewing
<br />instructions, searhiog r?istmg data sources. gadrerin~ .., sung d,: ;la~. ore d, and ,a>mple'7`ng and
<br />reviewing the collection of informaton. Stn.: coe-•ncr.~ ._._ ~~ tyo'f,u 1!c,r r limo,: or any othu ;b;re[t of
<br />this collection of information, L^.cludin. w_cew;r •~ thts hc~d;:n, to Chief, Informalior~ Policy
<br />Brmch, PM-223, U.S. Emironmraul Prot<xn~c .-.~. •'.:: ret, '. N' Washington, DC 20460; to the
<br />Office of Information and Regulatory Affairs, O1Gr .-. D.'.'tegrmrnt and I.u ,ret, \/ashiogtoo, DC 2050
<br />General Inst ru lctioi~s
<br />1, If form has been pallullr rompl.!-,, by preprinting, disregard Instant. ~~~ __:., .,r ~l;rr. ": Jrat nrurnuuicn
<br />already preprinted.
<br />?. Enter 'Prrmulee A~nme::llaiiing Addree'~ (and f citify aarnr:'~oc;.u: r. i
<br />"Disch,rrge.Numhei where ir.~icat,d (A separate form is required foi l,. I:
<br />. !'_nler dates beginning and cndn~, 1 ••~ ^p P,~ : ; :'cosered b:. tort:. •, 1.
<br />.. Entcl c-:-i "Pnramr•r. • ._. -' ~ ~ nlo:::rorine rtxwremcN:; ol'p_::1
<br />.?e:, ~,,, "/'ermrr :Vu.nher," and
<br />,.. ,
<br />: ~
<br />°nr.r ".~'a;^rlc A~e,iv- , .._. pa.-.ul:cter r,:':er ' i .. ., Muir s, ;:fi. i -. pcroii.
<br />', .. ... is nortna!L .: c ~ .•;~ ~ tea:,ma.nc z~..'r ~ _. _r. i ...:,~! r.m ;c :r, .,...cnien'•
<br />i•~r car' ,'tr. _..: 'ur ~1.:~,1:-~ng Pem, - .~. ~ :a:~. '. L. y~ ..,,. ..,.1
<br />nl:r' ,:." nr.l~urer,:ua; ,C' ,. ~ ~-~ng ''.r„oimrlr,~ :- ... .~, ~ ~.ui ,,;;.l:~.yu '?::;mc ..
<br />r.~rlw!:••~-n: Enl~• a,-0~1 :-._ cm,plc measur~.. a•. ~ ~ ., .
<br />•: J:I n: Lle nf:;ISVI?ilYC^:i Gh: ..: .., .: ^101:11Oring pi::L ....I:XI ... t .
<br /> 1
<br />•J r::if :1 r.r:. CL::': ::U n:~..' ,' `~1e r:~S1:"1?il' ;',~ ]! Illp,:~1yr
<br />...t .~. :,vat ll. (9r: (!."•:
<br />nnnimum ,~r `-d:+~ ~I c~agc l: s -. -:n-s~'' p: rm ~' r?qun..~1.uC 'ter ca:'!:. r .. ~ .. 1 . , ea; r. ' !'
<br />Enter''^qucnrr[n: ~
<br />~ ,, •i.:,,;nb• '. len•-,~. •n: ;ct.o i
<br />~ .: ::nl utr a.: r mr~is ,
<br />donne monitoring
<br />pariod? :.na
<br />"
<br />.'- ,ann., R
<br />~ .o nl !•
<br />e7~ Ir cl:x.fiez ;•
<br />'.
<br />~ _ „.. ~ /~ ..
<br />i 6 '. u+' .', c.r.,:mlo"
<br />~
<br />Inoniwrir.;.
<br />furnnrd,r.1-.~r'
<br />i .,.... _
<br />fa. one d.. rl:l<~.;
<br />.~ ~
<br />~' I .. :r •
<br />;
<br />Enter'~'amp:r 1',p~ hetF ;+< n, ,lfravrerrerr" !nn'„
<br />:lCll ,:11. ~. t.
<br />, . ~
<br />:1_:0;'1; !l. ?C 7G aj :.P;. IS
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<br />~uCrln/( !•.'equ/rP/nen r.' (P.f f: ft i c':
<br />'(; ~C}• fo( Indlr'f-j i!.i. ::loaf':. - ~ i0
<br />.- .. •
<br />conlinuoui monilori rg, N.: 1
<br />lU. Where r~olations of permit r.~y,,:«:ncnts are rcpxted. a':.;J, :: brief r,~ ~L, ... ~ to ..,.::.1;:: ca:~~s ;, ,
<br />actions L~l:cn, and rcferern°e cash v:olatior, bl dale
<br />I L If "no discharge" occurs ddrinr momforin~ penal entr.r'..:: D:.,char•Ke' r .r brn: p ice of r,:n.. ,;,:. .
<br />1?. Enter "lrcmelirle r;`Pnn;~ip,! F..ervricc UjTee•r' wr[f. "S'iRsature n! :'Pi~ ~/ i. Fi .::rive riJr..-: ,
<br />.~genl," "Telephone A'umber,' and 'pale' of bottom of form.
<br />11. Mail slgncd Report to OfficYfsl bi dale(s) specified in permit Retain G~h,' fc r ; .ur rc xdc.
<br />14. More detailed instructions for use of thts Discharg. Alone;:-r;ngRepurr ~i ~' ".t ;~~nn a :, :. `K r:b[:cazd (},. -' ~ ,
<br />specified in permit.
<br />Legal Notice
<br />This report is required by law (?3 C.S.C. 1318; 40 C.F.R. 125.27). Failure : r.i of ' .. -e to a.:p .n b 1.: " ~ :.
<br />result ir. civil penalties not to ezceei Si0.000 prr day of violation; or in cri min I ; .a . ti?s ~ or !~• ezceaJ $25 0'I'. _
<br />o(.'ullation, or by imprisonmrnt for nc: more than one year, ur by both.
<br />EPA Four: 3320.1 (Rev. ti8-9~
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