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PERMITTEE NAME/ADDRESS (Include Facili4• Name/Location iifDierent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES <br />NAME )' DISCHARGE MONITORING REPORT (DA1R) ) <br />ADDRESS CARBON .SUNC 7 IC N h}?? ? to.,_- <br />"I•6:z' ?:t?=yi:K13-00RO HIGHWAY PERMIT NUMBER 3E NUMBER <br />W I C. ••9I T A FALLS T;3 7` 302 MONITORING PERIOD <br />FACILITY CAF21;jN Ji,)#• CTION V IP•.zl <br />LOCATION t a YEAR MO DAY YEAR MO DAY <br />Forrn Approved. <br />V1 I NOR OMB No. 2040 X04 <br />F "- r-IislAL L_.F'=F. -1 <br />?ED'I 'POND TO CARBON •.JUNC"I' C .'t N <br /> T3Ji:?€1G£# <br />yT TP. E fit: F'(d / `U$ " i <br />° ` rtE ,:o o 61302 FROM <br />FAT I ? 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Sr:?T( <br /> <br />REQUIREMENT <br /> <br /> <br />t <br />#4L t ! <br /> <br />35 u ?. s <br /> <br />MINIMUM p ;#3t# 1r 1-7. 0 <br /> <br /> <br />) V1.4) x T MU#'3 <br />{7Pdt Et' <br /> <br />MLlnlTf~•F <br />!?l?.I F 4 <br /> SAMPLE <br />MEASUREMENT ' 1••r•fri. !: tc is#`; i.s:y:. r ) <br /> ,00!5415 1 0 C) PERMIT 3i #•3i 3t • •i <br />iti-• •t : c <br /> <br />E*F 'L ;.):t•:NT GROSS VALUE <br />i.?.tF_ ti, r,"s"l?c ? <br />^tl,a'•X t ra, i <br />REQUIREMENT <br /> <br />SAM <br /> <br />a : <br />s ?#.3.? <br />• <br />„<. <br />ry'?•=?- }t•}f•4 t£.I REPOJRT <br />•- <br />..:s?.Jl.}rry! #?'i14""a Q. 5 <br /> <br />€"'l e'. <br /> <br />lif..)i.... ONCE/ <br /> <br />MONTH aFR B <br /> PLE <br />MEASUREMENT j !.' <br /> i1211 5 e3`? PERMIT if R'?x## #?;? 1 li tc t l•y jf <br /> <br />E- F"L.f..ii N-!- GROSS 'cI'tASLUE: <br />FL(7t,:, :P'kk C0id.FE1U1 T ! c. <br />• <br />REQUIREMENT <br /> <br />SAMPLE <br /> <br />' #i?##ii i <br /> <br /> <br />: <br />• <br />• sF#te Liz <br />Ti?:l7ST i'?•61-` X <br />I'XZfI.. aNT'!tF <br />GIE1\1,!_ <br />aF?lhI3 <br /> .?F <br />. <br />T HRQ TRt--, 5 7'MI NT F'Lf?it?!"r <br />MEASUREMENT i <br />,) ;a? . <br />. <br />: '?.: ? <br /> ri0T0 501 ;• t,i »; PERMIT RE F0F <br />T REPURT <br /> <br />EF'FLuErtrr i-,,Ro a5 'JAW <br />304..:( <br />REQUIREMENT <br />SAMPLE , <br />30L-)A f•?V <br />t-3r3#d#i <br />DAILY 11 <br />;..s w. <br /> <br />?. <br /> <br />}: I TN-'7,E4/ <br /> <br />MONTH INSTA <br /> DISSOLVED MEASUREMENT s <br /> :- 1 O =s PERMIT 3Etm#? *r3i #3Y is# ' i8?3 <br /> <br />r=: T° 3" €_t•IEw€`w i" GR(.60S VAL.j iE <br />L? I L. AF'=`'B:) momE <br />> iSE <br />REQUIREMENT <br />SAMPLE <br /> <br />t 3: # 4E i . #!E#Y ?# REPORT <br />-30!?dsi AVi3 REPORT <br />l3A I tW `?' 6 1)C TRL_'Y" 37-R-A13 <br /> .. <br />W I9,-UAL MEASUREMENT <br /> cz til es t ; ID PERMIT ? )r•# tt W <br />-FORT t #•tE##•R•lf <br /> <br /> <br />I;T x: 11,_?L F ,` i ROE `i VALUE <br /> <br />REQUIREMENT . <br />r <br />1 NST MAX <br />m <br />? <br />"ass ? L! <br />##it•„#3?• <br />•3t••tl••?C•?#h• r <br />..si..h„l: <br /> <br />? <br /> <br />f <br /> <br />M <br />me'. / <br />CfFlTi-i <br /> <br /> <br />Z ? cal <br /> SAMPLE <br /> MEASUR NT <br /> MIT <br /> QUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE O FFICER I certify under penalt <br />of law that th is d <br />t <br />d <br />ll <br /> <br />AA ?r <br />, <br />rl y <br />ocumen <br />an <br />a <br />attachments were <br />prepared under my direction or supervision in accordance with a system designed T ELEPHON E DAT E <br /> ? <br />p / 1' t <br />T 1'I?G f V ?? <br />B to assure: that qualified personnel properly gather and evaluate the information <br />submitted. Based on my inquiry of the person or persons who manage the system, <br />or those persons directly responsible for gathering the information, the information <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br /> <br />GNATURE <br /> <br />(? ?p <br />N <br /> <br />TYP OR PRINTED I am aware that there are significant penalties for submitting false information <br />in <br />l <br />di <br />th <br />ibili <br />f OF PRIN IPAL EXECUTIVE 1 <br />OFFICER O 77 <br /> <br />C <br />OMMENTS AND EXPLANATION OF ANY VIOL c <br />u <br />ng <br />e poss <br />ty o <br />fine and imprisonment for knowing violations. <br />ATIONS (Reference all attachments here) R RUTH RtZED AGENT CODE NUMBER YEAR MO DAY <br />j m m £'~., - i ;:ii • '?,k `. ,. d ,P)k?'i h ' '^"o"? 1 Ir S.0'_• 7R, i.?t;i):.C "-'LF` EVENT, . <br />-; r..54_JE-."? t?.y t TO i;is L?t:f.i 13F i ?2ti4)F Fi1-1* N NY.1 3m <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 5 1 4S 4 1 <br />aTt"fOriTl. <br />000 ..1 . 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