Laserfiche WebLink
Form Approved. <br />PERMITfEE NAMEIADDRE55 (GrLbFSWryNr~lxeus~ I/Dtps..p NATIONAL POLLUTMT DISCNMOE ELIMINATON SYBTFM l/ppl(PDESI .c <br />NAME S t li dC d ,^. J A L C U d P AN T ~ DISCHARGE MONRORING REPORT lOM9l g1~ABDl~p't~04Q;Q0014' <br />n•rsi nFSr CRHONIC YET TESTI (~IddYY gkWl`Y1053 <br />ADDRESS DHAIIER p ~ (508R MV) 12345 <br />HAYDc'N CO H163~ o'IITNUMBER sc c eER P - FIAAL ~ <br />FAaLm MONITURI G' PER "' 14 J R <br />LOCATION ~ VEAR MO DAY YEAR MO DAY <br />HAYD <br />N <br />' <br />I: <br />CU Bl b]U FROM 99.:' p <br />1 T(~' 98 L'q 317 a <br />thl, fam <br />~EAR <br />~l <br />tln <br />Rtlon bi} <br />d ~S <br />C <br />E R <br />. <br />l <br />, <br />p <br />a <br />n <br />ie <br />NOT <br />„ <br />LTTN: G. HUD HRUMti GEA ERAL ltIR AGEk rso ~rl! p (14161 IZbI71178-791 /3631/ ~ <br /> PARAMETER !3 QFd Onlyl QUANTITY OR LOADING _ ~ nryl GUANTITY OR CONCENTRATION <br />~ N0. FAEdUENLY SAMPLE <br /> l3Z-371 !06531 150-erl <br />• y51 !4653 154611 EX TYPE <br /> ~ -~-AVERAGE MAXIMUM UNI~~ <br />~~~ INIMUM AVERAGE MAXIMUM UNITS res+m MALY95 <br />!64581 (59-)OI <br /> :EFrEC'f StATRE 7pAT SAMPLE .n ;~*~#rta a#aaaa ###aaa a##### ( $3j ~ <br /> CBX CEdLUUAPNBIA MEASUREMENT <br />„ .. v <br /> ` 'PERMIT .: ~ ... ........, v <br />....., <br />~ ....:. . <br /> <br />see col~n~aTS yF ~ REQQIREMEN7 <br />,.:,~._:....:..:... .. .. <br />..,::,:;.':'>r:r . <br />~>::.~,I ...:.. ... .: .. <br />~:,~. ,..::: .. <br />##aa r. <br />::....: ~:.. g: ~a'a .s: <br />: ::':'=mx>€.<.<.. <br /> :EFeECT sTArRe 7DAT SAMPLE C;:R+Y#A s0#a#o #####a d1 +6##O# ~ Zl) <br /> 'HH eTnriek Ates MEASUREMENT <br /> <br />YCebC 5 2 0 MIT....:. <br />:'~. .:.;;~:.<::.::;..,.. <br />:;4010as+ip~~ <br />`~' <br />: <br />"y;~1Y~.PAr <br />##a <br />1.5:.t#.:,:. <br />' <br />' <br />'c <br />:'l~talE#gi?Pt:.: <br />.~;`.A!9r+0##~~~ <br />~ <br />':;:: <br />ER- :,s::r%" . <br />r <br />: <br />I ...... .....::. <br />..:~ <br />~': <br />:: ~: .. <br />~~8 <br />:. <br />' <br />+ <br /> <br />SEE CUMtItiiTS H2L'Jr <br />REQ 1 F~E4M„Lf. .. <br />:': , <br />,..,.." ,:..... <br />#C:G >:., :: <br />.:,: .; <br />: <br />~ . <br />: <br />;: :; <br />;z <br />. <br />I ny,r•: . <br />; <br />~:'~ : <br />. <br />:: <br />. <br />. <br /> SAMPLE ~~": .,~ ~ ~~ <br /> MEASUREMENT <br /> .,,:. .: PERMIT ` ~ ~ ::,~~«t;,t:.,~:::.:~: <br /> <br />~ <br />' ~ :~. ~ ~ ~~ :.:..: <br /> <br />~ <br />~ . ~ _ <br /> <br />~ ~ <br />,.... <br />: <br />., <br />; <br />:~; ~-s~~ :: <br /> :REQUIREMENT. ~ <br />r~ <br />:`.+'::; ;xao.:e::: : <br />. <br />::~;... , <br />::: <br />. <br />::<. ,: <br /> SAMPLE - ~ ~ ~~ <br /> MEASUREMENT <br /> <br /> <br />E <br />R <br />ENT ,, .. <br /> <br />: <br />~ <br />~ <br />:.;:':. <br />:: <br />~~; <br />~ <br /> <br />ysaa. <br />~~: <br /> <br />. <br /> QU <br />EM <br />,A :.:...~: ., <br />«.,..:~.. ~: . <br />:. <br />. . <br />. <br /> SAMPLE <br /> MEASUREMENT <br />~ <br /> <br />::•.~.~. PERMIT.. ~ <br />..:.... ..... <br />~...... ~ ~.:: <br />....:. . <br />~ <br />tsa"i;:• ::.:: ........ <br />.: 5 -.. :...:....... .. <br />.. <br />,. ..... <br /> <br />.. <br /> <br /> <br />..::.:.:....:.:. <br /> <br /> <br /> <br />'~~ <br />" <br /> <br /> <br /> <br />'< <br /> :REQUIREMENT: .. .~. ~.t.:: ,:^: X].',.;3;::. ~.:.: ~.: .: ...~ ... :.,:. :.. i~ <br />j <br /> ..:.':..,. .. .: ..1......' .:: ...'. .. :.. p..:. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT.,. <br />.. :>s:.:.' <br />s::'!7.~: :''•.-:..::':;: <br />< <br />~;;:~.~::;: ~.:: <br />' :. <br />;;~,.,~ <br /> :REQUIREMENT . <br />. <br /> SAMPLE <br /> MEASUREMENT <br /> ~~~~ PERMIT'.... .. ..:: _<:: ~..:.. ;:... .... .. <br /> :9..EQUIREMENT:: .~:. .. ~ ~~~ ~~ ~:~~ ~~~ <br />-:.. <br /> NAMElTIttE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF UW THAT I HAVE PE1150NALLY E%AMIN <br />MD BA <br />AM FAMILIM WITH THE INFORMATION SUBMITTED HEAEIN ED MD <br />SED ON I ` TELEPHONE DATE <br /> ; <br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIB LE FOR <br /> <br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMA <br />TION IS \ <br /> TRUE, ACCURATE MD COMPLETE. 1 AM AWME THAT THE <br />IN <br />AGNIflCMT PENALTIES FOR SUBMITTING FALSE INFORMATION RE ME <br />CLUDING <br />Z <br /> , v I1 7 <br /> THE POSSIBILITY OF RNE MD IMPNSONMENT. SEE 18 U.S.C. f 1001 MD 93 TUIIE OF PRI AL E%ECIJTIVE <br /> u.s.c. r t 9t,. rFrl.re.. aria! elra. mnm, m.r bcE.d~ r.M. w ro t ro,000 BIONA F <br /> <br />TYPED OR PRINTED <br />.nla+mvwll.nin.ric+vn.nr of Arfrwlema+rers rr06rra/ <br />OFRCER ORA ORIZED AOEM <br />CODE NUMBER EAR MO D <br />COMMENTS AND EXPLANATION OF ANV VIOLATIONS !Reference el/ettschmenrs hers! / :~ <br />~~ <br /> <br />.EPA Fam 3320-1 108-961 Pre~iou, editions mey be,uaed. /REPLACES EPA FORM T40 WHICH MAY NO.T BE USED,! PAGE . ' <br />Q0076L'9.80914-0923 ; <br />' 1 <br />r <br />: <br />.. . <br />..: <br />.. ; <br />..A -:...... ~ .. .. <br />