Laserfiche WebLink
PERMITTEE NAME/ADDRESS (Include FaciGry Name/lacaxon ijDi_Q'neny <br />NAME <br />reA~pes NINI',+s, I', C. <br />ADDRESS= $,~pS~~E$~. NINE <br />P. ~'~i 187 <br />FACILITY `g ; ~:' ` `"'D N1 <br />w dh,t: . <br />LOCATION ~' ,.{: :. } <br />~: `s <br />'. i r,r: `"N °~:~aoE !~~ETEdU, PHF.S/;EN <br />FAP:gMETER <br />- - <br />~~ NATIONAL POLLIfiANl DISCHARGE ELIMINATION SYSTEM (NpDES) ~ FORM ApprOVed. <br />DISCHARGE MONITORING REPORT (OMRJ OMB No. 2040-0004 , <br />!lINOR <br />(SUER NN) <br />P RMIT NUMBER DISCHARGE NUMBER p _ FINAL CIO F A T <br />5 MONITORING PERIOD @OND f 2 TO EAST BUZZARD CULCH. <br />_ YEAR MO DAY ~ YEAR MO OAY ~7r '~ <br />- FROM ~0 0 TO 0 2 '~#~ NO DISCH~R6E 7~(. #~"F <br />Q ~ ~-~ NOTE: Read Instructions befo! . IeGng this form. <br />QUANTITY O.R LOADING QUANTITY OR CONCENTRATION NO.• pREOUENC SAMPLE <br />£X' op TYPE <br />ANALYS/S <br />-: AVERAGE MAXIMUM UNFTS- ~ MINIMUM ~ AVERAGE -. MAXIMUM ~ UNITS. _ <br />~, ~I - <br />~ ;.i 5AMPL~ a#~#04 #aaaaa ~ ' <br />~ <br />- • ~ ~ ~:a ~ ~~ <br />• <br />t <br />t> MEASUREMENT <br />uoavo . <br />, <br />' <br />eFFLUeNi CROSS r <br />L rt '''r~ r <br /> <br />iOLIU~, -SETTLE <br />AB <br />SAMPLE <br />6.OrrOM# <br />~ <br />'~~~! ~ <br />` ' <br />7r r~ <br />;'°'"1'7" <br />' ME/S$UAEf7j~NT '~~ <br />UUy4S 1 'J U <br />` as fr <br />LP94UEN CRD55 VaL~Uf ~«aaL `- <br />JZL AND. GREASE SAMPLE '. 0olfb~>k «eaa o <br />~ <br />~ saoa <br /> REMENT - `~ ~ ~ <br />u3saz ~ };~. v ` <br />rF'FLUBM -~ 5 PALO <br />~ ,.~ ari'_~. # ~!~ <br />t'LJN, Y ~ IT DR; ~( ~- 3)- k #a: <br />:r{RU T$&; LAN MF~+ ENT ~ ~ 1:T_; <br />~OOSU ~ <br />t ' <br />4jy <br />;.F'PLUEr~. ALU T - <br />~:_;LIDS,-; si~MPL #a¢ +aR•a 4#trs <br />UL~SOLV MEsfI.StIREFN <br />IU295~ ~ <br />0~''sp ~ 4## <br />; <br />LFFLU~ ~'3GRpS , <br />'• Lu ~ ~ ,iy <br />~~"+ a <br />JIL AICD-•C,~AE- $ -~'' <br />F Z,. SAMPLE ~~ 3!@, st# 9U) ~ ViMr. a <br />VISUAL.;::` `, MEASUBEMENT, _ <br /> <br />t;FFLU CROSS Y "~ N030- <br />~ . '' :~A14iPLE <br />~':~ ~' -r REMENT <br />M~ttSf3 <br /> , <br />itsaaa <br />F •.~, <br />, <br />NAME $PRINCIPAL EXECUTIVE OFFICER ICedity under penalty oNaw shat Ibis document and all ahebhm4rYS were ~ ~ ~ <br />- - - <br />- - - - - -~- - - - __3£LEf?NON6-- -. - - DATE -- <br />T~ ~ ~ -' - - prepared under mY tllrectWn a suppreeN.ison i~~Sl~npe w1lRasySenideaigrwd--- <br />- _to assuTelhTquaTiFedpersonneTproperlXgamgrand evalu~to lne inlorry,aaon - - - <br />~ <br />~ <br />~~G <br />~^"-- <br />U ~- <br />41. w{~OG. <br />:P@C@LB subm"led.Basedonrtryinquryolthepereonorporson9whOmana9etfie5YsYom, - ,r{ 970-834-4401 l Ol 16 <br />j lorgaNarin9theiAeffAahon <br />mefnforlnatlon <br />or nose personsWreclJyresponsAle <br />r <br />PTeai~l <br />tlG@n@Tal ~18TU1 9Y <br />P , <br />. <br />l <br />i <br />f <br />kn <br />l <br />be <br />f <br />t <br />d <br />l <br />t <br />b <br />.. p <br />+ s ,tome best o <br />my <br />owlef <br />ge "nd <br />e <br />, <br />rue, a <br />cure <br />e, en <br />comp <br />e <br />e. <br />submMed SIGNATBRE OP PRINCIPAL EXECUTIVE <br /> <br />~:-- <br />~PfYPED OR PRINTED I am aware that mere are signHlcanl penalties Mrsubrgilang lake infomyuon, <br /> <br />inclutlin the ossibili of fine and im risonment for Rnow' viola:lons OFFICER OR AUTHORIZED AGENT <br />N MgER . <br />U <br />YEAR, <br />MO <br />DAY <br />COMMEN ~ AND EXPLANATION OF ANY VIOLATIONS (Relerenca a/I attachments here) ~ ~ ~ ~ - . - <br />S~'iT[,~A)I.L~ SJLIDS LIF:IT M0.= BE RAIYED FOR >iOTE,Z+iHR PRECIR EVENT - S8E At<TERNATS LIiKYT44I0ifS UYD$I: <br />i.A•1.'D~ 71ND ALSO BUHDF.R <br />^ OF PROOF RF.aUiRENENTS UNDER I.A.3. OIL.6 GREASE - SEA, Z.B.1,:(DJ: T65 <br />orm 3 -1 REV 3(9 ITrevlous e i Ions may be usetl. ~ - <br />E _ _ ~ A " ~°"' °~~'- ~""- <br />