....,nee nArtWppRE55 /Tlnhdr ~. .. - .1.- ~. ~ nnr
<br />FaYiry Namr/Lonrinl U ., .~. .'1: rFy':~, p
<br />NAME - ~ ~ - '~
<br />CY CDdl.SO_ W-U.CL~~7Z71E~'~_-_. .~
<br />ADDRESS 1 ~(„1 QSI ZIS _Y.AS.~ _ ~ _ ~~~~.;. _, ~:..-_. . - I
<br />ar.i
<br />' LOCATION__-_-___-_-_-`-'~^•~. a.~--- '~FRON
<br />a Trn• nrcrrra..rwrvu ~-~. ---- - .
<br />'GE ELIMINATION SYSTEM (NPD£SJ
<br />
<br />ORINO REPORT (DMR1 •
<br />I
<br />I
<br />~ STORt1WAT£R'~' SPOIL S^f?G E Y:I~tCR
<br />c OISCNARGE NUMBER
<br />- ~- i-'-" -` - -"
<br />Dpl 'P RIOD
<br />~
<br />~
<br />. I (YEAR 1 MO ~ DAY i
<br />I "~
<br />~
<br />-
<br />I
<br />To 51 u YT `tO.R, ! ttl1TR5.
<br />I - . ~...abrn /zasv~ /343!1 NOTE: R~'bdinbtiuedons lielore completing this lorrtl:
<br /> 'O Card Only) ;. QUANTITY OR LOADING ~l~Card nly) QUALITY OR CONCENTRATION
<br />' INS: REO
<br />UFNCV (SAMPLE
<br />PARAMETER ~ 1.. ~ (IbJ3J';.i. ~ (Jiff!) '
<br />- /38JJ).: ((6531 ISI-61) SEX O
<br />I TYPE
<br /> ~ S
<br />pldl) ~ ~
<br />m ~
<br />~ 'AVERAGE , I ~ MAXIMUM
<br />I , ~ UNITS ~ MINI+.AUM ~ I AVERAGE i MAXIMUM I UNITS ~6:-63 IA/6I~68) I (6P-701
<br />tL AGG l'. ~. E.13E SAMPLE '.~ !b~v4~k0
<br />p
<br />~ ~ i - Yt ;}S: 4~t:# i ..:-'.nXr:+tX Y::};: {::: lY ~ I 1.• L
<br />'II JUIIL MEASUREMENT . r -.
<br />si. ~. yv r' ~ - I :. ~.. _
<br />_
<br />dgO66 1 d -U PERMR . ~ :"y'-~I~Ip#fllh"_ 0'`? ~;
<br />.
<br />. :.'~-1' '.#04av ..aS4YilAla '64•arir=aO <<~Y " IirBKLY, ISUAG
<br />~ F, r ~ ~REOUIREMENT r'•Y< t .
<br />.
<br />~ ~ M'_,
<br />I .
<br />T,' _ (
<br />~{`({(7.({i , ~ ..
<br />1 1 '
<br />I:}r1Cr_ i _ n _
<br />I ~ I
<br />I
<br /> SAMPLE 4
<br />m ~4y~
<br />I!'
<br />-
<br />'
<br />- I .I
<br />I ' ~
<br />~ ~ ~ I I
<br />'
<br />. NEASUREMENT ~..
<br />, F^+~.I-.Ly~
<br />` G - ~i
<br />... - _ - ~ ~ ' ~ , I I
<br /> -'] PERMIT ~~vA'''
<br />REOUIREMENTG I', ~ ~ ..
<br />~
<br />4 ~ ..~',1y :, _
<br />~.-~
<br />~
<br />~ I .. ;
<br />4
<br />M -
<br />i 6 V
<br />v ~
<br />~ I r.
<br />r. i "L
<br />~ ~ r
<br />( ~ I
<br />I
<br /> KKK
<br />, _.
<br />r
<br />P: Y .
<br />:.
<br />.
<br />. i .j I ~ r ,.~ I
<br />' SAMPLE i _ '_ ~ .. ~ j I ' ~ ~ .I I
<br />- - .
<br />MEASUREMENT/~
<br />w
<br />:a~•:~-.. P
<br />~ ~
<br />t:. a j (-
<br />- .
<br />:~ -.
<br />~ - ,
<br />- I I '
<br />- .-
<br />
<br />~~ PERMfh'_~S
<br />
<br />' i
<br />~,
<br />xrypyt;•<r ~,i;.~ ~ ... 7. .[.(. _
<br />~ Co..r-
<br />`l
<br />'
<br />~ _
<br />{ ~ C' ~- 4
<br />~/ _'r k-~ _ -. ': 1
<br />1 `" .`+ ~ ~ G e
<br />.~
<br />f
<br />~ I
<br />_ ,r.. -
<br />I_ - ~ ,
<br />I I
<br /> R
<br />EWIREMENYS3 '„ <,' :.~ ,.
<br />e
<br />tJ...`t.
<br />Li r L. - 1~. al i
<br />-
<br />' I 't I •
<br />' SAMPLE y '. ...M -'
<br />
<br />°
<br />-
<br />
<br />-
<br />
<br />~ i y
<br />
<br />I = ~~ I _
<br />
<br />- -
<br />
<br />+~
<br />~ Y
<br />i
<br />
<br />~
<br />
<br />.
<br />ai-
<br />-
<br />_•• MEASUREMENTU 1
<br />i-
<br />~ I _ - i
<br />f
<br />.
<br />~~ .. ..- ~. PERMR' .~
<br />~ ~,y"z'i-` F '-
<br />- a>, , I "ia. z}
<br />{{ • .~
<br />= i ~ - f a :a I~. t',
<br />L+ cl `f' I b.
<br />I i ~
<br />• ',. ...rr, I ~
<br />:' n - }}
<br />' ° ~
<br />• s I
<br />I - .. I
<br />!
<br />..ti REOUIREMENT
<br />r .Z ; ~
<br />{;;'LI 'Vi'i:/-~, .~
<br />I•~t .7....•3,5 '-F. _ C C' a, -c ~
<br />ri -
<br />I n'. ~. .F :S'7 i ,
<br />.. ]" SAMPLE M1:
<br />' ~~'^
<br />' _ ~
<br />_ t ~~ I: I. I
<br /> r
<br />MEASUREMEM ~.'A`.. _ w - - - - 5 .
<br />.. x
<br />' h ~ PERMR '-•~
<br />P ~~.Ix~ ~.V~ ~
<br />~~,~
<br />~ c ~ qr ~ .... x:. ._
<br />~
<br />~
<br />~'' ` j •=
<br />~ ~
<br />' i
<br />I Ij
<br />' i.
<br />I: ~ _
<br />.,i. ~ I~
<br />., EOUIREMENT ^~
<br />,
<br />Y
<br />, ~
<br />:
<br />.~~si~ t• I~ C
<br />If: =A' ;
<br />a .~. ~ ~ ~. ~ '.~^f ' .I ~~ I
<br /> . I
<br />~ .
<br />-
<br />.
<br />' MEASUREMEENTt_ `
<br />G • j
<br />,
<br />I `Y •
<br />~ ~ ~ . : ~ ~ ~ _ . ... i ~ . ~ .
<br />•
<br />~ >
<br />.
<br />.'
<br />a . .. ~ -
<br />.- - i1, PERMIT. ~ -~
<br />T
<br />`
<br />" " 4 ':
<br />'~' ` I ,~, Sy , Lµ i
<br />- L p r ~ t ~ C Y ~ .' 1' ~•
<br />~
<br />~ i. _ i'_ I '
<br />_ _ y
<br />~
<br />REQUIREMEN ';~ .~,G+
<br />f 'i I ^~ ~
<br />~~
<br />-
<br />q~ i C A
<br />O
<br />3
<br />~ 1 '.
<br />- t.
<br />L -( _
<br />' I - 19 - ..
<br />- ~ ' .
<br />; ..
<br />. c
<br />. _
<br />._
<br />- r
<br />-
<br />•v
<br />- SAMPLE ~'
<br />MEASUREMENT~ . IC R ~~ ~ C w
<br />~ `
<br />"
<br />~ I .._ ~~ ~ ~ ~
<br />.. - t
<br />I
<br />_
<br />_
<br />C j ~
<br />. C
<br />~
<br />? ~
<br />' PERMIA y{j
<br />R n_
<br />:'-
<br />.~
<br />:'t~• 'C _ '.
<br />~ ~~'yi ° 7 ~ I ;t =w C :` o
<br />. .
<br />r- ! .b :t
<br />S
<br />' ~ ~•
<br />~r I .
<br />n
<br />'
<br />_ .f
<br />v EOUIREY t,
<br />.~ ,1a, ~ i ~.~.-G.~ ~ '
<br />~ _
<br />J ~( (.
<br />~ ,
<br />; ~.~
<br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I CERT
<br />N
<br />AM FY UNDER PENALTY.OF UW THAT 1 NAVE P
<br />FAMILIAR W
<br />TH THE INFORMAT
<br />N SUBMITT ERSONALLY E
<br />EREIN
<br />ED
<br />A XAMINED _ - ~
<br />ND BASED
<br />= ,' TELEPHONE ~ DATE
<br /> A
<br />I
<br />IO
<br />H
<br />;
<br />- ~
<br />_
<br />D
<br />_
<br />~ ON MY INOVIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOP
<br />
<br />~,
<br />~ - _ _
<br />OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION _ t
<br />~
<br />
<br />~
<br />• _: •-~ ~~
<br />~
<br />' IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE.ARE SIG
<br />~ . ' u' ~
<br />-
<br />'
<br />_
<br />:
<br />{ HIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />F F
<br />E
<br />S
<br />'
<br />~
<br />~
<br />' -
<br />. 7,( ~. ~
<br />: _
<br />~ IN
<br />AND IMPRISONMENT.
<br />THE POSSIBILT
<br />O
<br />EE 1B US.C..~ 1001 AND SIGNATURE OF PRINCIPAL ECUTIVE
<br />E 7779
<br />IY
<br />l
<br />i
<br />E
<br />a
<br />aCO
<br />77 US
<br />C
<br />/
<br />d
<br />F /~
<br />' '
<br />s TYPED OR PRINTED . /
<br />w
<br />r
<br />e w
<br />rr r
<br />m sreryrrt maY Nr
<br />u
<br />.
<br />.
<br />r Ina u0 ro
<br />/a,
<br />_
<br />aMOrnmbnarn lrrrp4aamrnryGrr.arnbmonrhraney/eon.l ~ OFFICER OR AUTHORIZED AGENT I NUMBER 'YEAR MO I DAY
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS(RrJaiural/alTSrhmrna Aerc/ ~ I
<br />OIL At7D Gk LASE: .~E£ FGOZNOi£ ~'/:.(O--HllS? R!P(iBT Tf' E$~HPSIONS CLAI."tEG. TSS gbS'f ~bf. H%f''09TE0 AT AL1, i
<br />EFA FOrm 3320•T(RDY. P881ProYI0U•I IIdiflOOS mly Dl USld.- (REFUGES EPA FORM TJO WHICH MAY NOT OE USED) PAGE OF
<br />''i ` t, .i
<br />
|