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►ERMITT[ [/ADDRES@ (lrttludr NATIC'NAL P(11.1-I1�DISCHARGE ELIMINA7IUN SYSTCMormA <br /> facdlt) Nam�allon it dllfrrrnt) PPIOYAd <br /> NAME— MID—CONTINENT CURL C CLYECu DISGHA MONITORING REPORT I//1IH) OMB No.2040-0004 <br /> ----- - - ____ (z-Inl (17-19) F — FINAL Approval expires 9-30-85 <br /> ADDREss COX 1ND __ 00000.396 EOZ <br /> BSEGT.9 FOR=10YR2HR <br /> --- CARBOND — _------ CO 81623 — PERMIT NUMBERARGE NUMBER <br /> -------- <br /> MONITORING PERIOD <br /> F�I CILITY---- <br /> YE�IMO DAY YEAR MO DAY <br /> LOCATION — ------------------ FROM TO MINOR <br /> ATTN: DOUGLAS BOWMAN ENV CUORD (20-21) (22-23) (24-25) (2627) (28-29) (3u-ill NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (38-43) (46-53) (54.61) NO. FREQUENCY SAMPLE <br /> (32-37) of <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS T>- YPE <br /> PH (61-63) (64-68) (69-70) <br /> SAMPLE �' *7�cJa7k 4c 4 *#** <br /> MEASUREMENT <br /> 00400 1 0 PERMIT ** ***�t*# x� ** 6e5 ****** 9.0 aEEKL GRAB <br /> EFFLUENT GROSS VAL EQUIREMENT ** <br /> SOLIDS9 SETTLEABLE SAMPLE <br /> MEASUREMENT <br /> 00545 1 0 PERMIT *�a**** *** * * * ****** REPORT 0.5 ONCE/ GRAB <br /> EFFLUENT GROSS VAL REQUIREMENT <br /> OIL AND GREASE SAMPLE ***�[ <br /> FREON EXTR—GRAV MET rEASUREMENT <br /> 00556 1 0 PERMIT <br /> �`�"�*�`* '� '�`�"° '6` REPORT 10 <br /> EFFLUENTWEEKL11GRAB <br /> ** <br /> FLOWr IN CONDUIT OR SAMPLE ***** ** * <br /> THRU TREATMENT PLAN <br /> EASUREMENT <br /> 50050 1 0 PERMIT.REQUIREMENT ORT REPORT ****** ** ** *#**Ipl *** WEEKL INSTA <br /> EFFLUENT GROSS VAI LINST MX MG El <br /> SOLIDS9 TUTAL SAMPLE <br />' DISSOLVED `MG/L ) MEASUREMENT <br /> EFFLUENT <br /> 1 0 EQUEMENT ****** REPORT REPORT QTRLY GRAB <br /> OIL AND GREASE 90DA AV <br /> SAMPLE <br /> VISUAL MEASUREMENT ** <br /> 84066 1 0 PERMIT R EPURT ****** ES=1 HEEKL VISUA <br /> EFFLUENT EQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY TINDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED TELEPHONE D A T E <br /> /D�� ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR !- <br /> V OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION \7\ ^ <br /> IS TRUE ACCURATE AND PLC <br /> F. I AM AWARE THAT THERE ARE SIG <br /> NIFICANT PENALTIE5 FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITv OF FOR <br /> AND IMPRISONMENT SEE IB USC S 1001 AND -- �/ <br /> 33 US 5 1319 rpertaltu. urulr, rh r star r uu lud,•/rnr. uy n, fla nrnl SIGNATURE OF PRINCIPAL EXECUTIVE ' <br /> sad ,v ma omum mI ... n.B..numrh.-nnJ' - —_— <br /> .TYPED OR PRINTED p".""'I '"r"lh OFFICER OR AUTHORIZED AGENT <br /> AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Kr/vrtvrFe all uttmlrntrnrc hetr) CODE I <br /> IF NO DISCHARGE OCCURS REPORT "NO DISCHARGE". SALINITY SHALL BE MEAS.AS TDS=70295 MG/L. <br /> OEG NOW 2 PRAM-NU SHEEN:84066=01,556-0.A SHELN:84066=19556=GRAB SAMPLE. <br /> EPA Form 3320•I (Rev. 10-79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.) <br /> UNTIL SUPPLY IS EXHAUSTED 0061- 12JI00686-16-r 6 PAGE I QF <br />