Laserfiche WebLink
- Form Approved. a <br />PERMITTEE NAME/ADDRESS(-weY/riaeWryNaw/tocarrowl/D(QGnrnr) <br />NAME SXI~DI~ MIIVII~IC: LL.~ <br />ADDRESS ~iN$CtRN ARK ~c EL.6'S ~l;li P'lINES <br />F. (.~. S~SX 53a <br /> <br />f/-carn S/~,NT~©I~~1 CEii~C ~ EL_l~ u~tli MINES <br />LOC/1TION ~jI~MER S~'T ~ C1 8 i ~• w"s4 <br />~-rT>+1• . t.~rrlT.:c: -r ^nncs~°a. szY>^t` it n <br />NATIONAL POLLUTANT DISCHMOE ELIMINATION SYSTEM INPDESI OMB No. 2040-000,4 <br />DISCHARGE MONITORING REPORT /D R) ~ ~ N~aC•? <br />{~: L{;~C~~J~ i 3~! C} 3. ~3 /'~ 4 a~1~3~ left-~ :I <br />PERMIT NUMBER olscHAROE NuMeEa ~' - ~' T I'~3taL £~'1JN I <br />~%JN£~~°F' "~ £~ 1'~? ~'t:IRY~i G'k..li~sicl:i.~t:31~ ~. <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ TO ~ #-I`'t- {'.[(~% ~7~;:~~f-iA4~C;~ ¢yX,f •#;••Tr••1r <br />NOTE: Rud ImtrucNom baton compl~tiriq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION nJO, FREOVENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />C1IL_ Afir1I} GREASE SAMPLE ##iFib## { ~'.4~ •#}###•dt#.• ##•1;-3s•#3s.- #-i-~•~,`~ <br />V I SUAL_ MEASUREMENT <br />t~~4Ub,~ ~. ~? t~ PEfiMIT' ~-s~#tf#,,t- fiEPO T ~ rS =]. ###~#~t ~####•~•# ##~~-~•~ I•### ~ 1 I~l1A <br />E~'FLtIEhlT s~~D~`~S "~ALiJ R~gUIREMEyT <br />,..:.... IWST• MAX h1Ci=t? #•><•>ta~ tiClNT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />........... <br /> SAMPLE <br /> MEASUREMENT <br /> ;:PERMIT <br /> REQUIREMENT'; <br />_ _.._ _ <br />................. ............ <br /> SAMPLE <br /> MEASUREMENT <br /> ...::PERMIT <br /> REQUIREMENT' <br />::. , <br />_. <br /> SAMPLE <br /> MEASUREMENT <br /> :PERMIT <br /> FiE~UIREM~Nt <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ', , <br /> SAMPLE <br /> MEASUREMENT . <br /> <f+ERMIT <br /> REClUiREMENT <br />........................ <br />..................... ... . <br />.......................... . <br />_ _ - <br /> <br /> <br />- <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER -- <br />' «rhty u er pena q o law that Ihb doavmenl and NI attachmenU weR <br />dlrectlon or superWlon In aceordan« with s system dai(ned <br />pre <br />ared under m TELEPHONE DATE <br /> <br />J G V+"P S ' p <br />y <br />to assuR that qudlEed personnel properly ether and eraWale the Informallon <br />Eased on my irpulry of the person or penoro who mana(e the system <br />submitted '.... <br />~ <br /> . <br />, <br />or those persorts directly resporotble for plheAn( the Information, the Intorm.tlon / <br />~,/~-- <br />`~`'y I x( <br />~~Jp Q// 9_ / <br />' <br />/ <br />~ <br />pQ <br />>1 <br />X~~ r ~' C ~ S / "'"` h~ submitted b, to the bnt or my knowkd(e and betlef, Irve, accurate; and complete. <br />dIONATVRE OF PRIN Al EXECUTIVE / ~ <br />/ 7 <br />/d ~ <br />(/ p ~;7 <br />G- 1 am awaR that IheR are sl(nIE«nl penalties for submittln( hbe Information, <br />TYPED ~ pR~~p Ittdudln( the poslbllity orEne and Imprisonment for knowin( vlolaUons OFFICER OR AUTHORIZED AGENT CODE 'NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Rtrf~r~nc~ s// ~tncnm~nts n~r~l <br />TSS °c TC)Ti'tL IR~JhI LIMITS WILL.. )iE WAIVED, 14h1t"/ SIrTT'L.EAT~'i...E St.JLIti~a LMT FtFfiLIED FOR •:=iCt''t'Rr ,=~4HFti I'RECIP EVEt~#T~ <br />SETTLE.ALLE SOLIDS L3:MIT MAY I3E W~tIVED FLIR ~>iC~YR.24t-tR EV1=t~IT-SEE I. ~. it PP ~i•-~„ AP~3~ .~. tit. ~r P. ~ FQR RGt'fl`~TS. <br />...... <br />.... J ..~:,L r ` F s-. <br />EPA Form 3320-1 (Rev. 3/99) Previous editions maybe used. i s ~ YY T~us•~S.~4-Dai'[..7otTt1. ...~ <br />