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PARAMETER'
<br />(32'-37) `'
<br />`
<br />• u ,
<br />t
<br />(3 Card Only) - QUANTITY OR LOADING
<br />(46 -53) (54 -61)
<br />(4 Card Only) QUALITY OR CONCENTRATION
<br />(38 -45) (46 -53) (54 -61) -
<br />O
<br />:X
<br />(61 -63)
<br />FREQUENCY
<br />OF
<br />ANALYSIS
<br />(64-68)
<br />SAMPLE
<br />TYPE
<br />(69
<br />Ai/ERAGEI
<br />- MAXIMUM
<br />UNITS •
<br />, MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />R i) -
<br />_
<br />.
<br />1.3 4 0 0 1 0- -
<br />+ � - G
<br />..PFLJF +. ,:�C25S VAL��
<br />- SAMPLE, --
<br />MEASURE C
<br />41 44 fAttt*
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<br />PERMIT '
<br />R EQUIREMENT !
<br />is
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<br />SAMPLE i
<br />MEASUREMENT
<br />Ae.'M - **
<br />1 By�
<br />****41.73
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<br />-- PERMIT Wa
<br />«�
<br />REQUIREMEN
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<br />9, �:tC4 1 41
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<br />', R L U N E A T R- G R A _M E T t`
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<br />i. F F L ; I c t; T CROSS
<br />SAMPLE
<br />MEASUREMENT G
<br />Q *1441.711;1 :
<br />Q, 13
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<br />• PERMIT: - t
<br />REQUIREMENT •••
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<br />w'VALUE
<br />�,J�, I CONDUIT OIL
<br />8 U E N T PL AT ;T
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<br />FFLUF.tiT e9035 'VALUE
<br />SAMPLE
<br />MEASUREMENTS
<br />„
<br />� 1 ` c.11
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<br />/0295 1 _.0• -0 ._
<br />?FLUENT GRO VALUE
<br />-:, SAMPLE 0c.
<br />MEASUREM r.:
<br />a- 41 .
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<br />- 4 -�.ti
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<br />.s PERMIT! It:
<br />REQUIREME}4T
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<br />(JAL _ n -
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<br />S AMPLE fy
<br />MEASUREMENT
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<br />ti PERMI1 .
<br />REQUIREMENT
<br />y
<br />+::` 441 **41 -
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<br />SAMPLE '
<br />MEASUREMENT _
<br />W' .6 ::^.:::
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<br />it PERMIT
<br />REQUIREMENT
<br />14d , ±
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER -
<br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED
<br />AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED
<br />ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION
<br />IS TRUE, ACCURATE AND COMPLETE, I AM AWARE THAT THERE ARE SIG-
<br />NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT, SEE 18 U.S.C. 4 1001 AND
<br />33 U S.C. 1, 1319. (Penaltks under thou statutes may include Jinn up to 510,000
<br />andor/ narimumlmprisonmentoJbeturen6monthsandlyeaa .l
<br />- 7
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<br />TELEPHONE
<br />DATE
<br />,�
<br />B T t,. J.. 1'Ii"c:•f.. -
<br />2 t( Az.....,,
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<br />SIGNATURE OF PRINCIPAL E CUTIVE
<br />OFFI CER OR AUTHORIZED AGENT
<br />TYPED OR PRINTED
<br />A
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />PERMITTEE NAME! S (Include •
<br />£.aboNome /Lotatu rent) .• '
<br />NAME_ PLA, Y COAL CO' ULUCLA MIt1W
<br />ADDRESS COUNTY ROAD AA__ t
<br />FACILITY - - — —
<br />_..... ON_ _ -- - _ - - _ — _,- 1- — -- _ —
<br />ArTs : LIE t4x 13 :STt.VENSON PHES 1 N/
<br />EPA Form 3320 - (Rev. 9 Previous editions may be used.
<br />NATIONAL POLLUTA
<br />DISCHA
<br />(2 -16
<br />C00
<br />PERMIT NUMBER •
<br />•
<br />FROM
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />I? NO DISCHARGE OCCURS hFPOAT H NO DISCHARGE ".
<br />(20-21) (22 -23)
<br />HARGE ELIMINATION SYSTEM (NPDES)
<br />NITOR NG REPORT (DMR)
<br />(17 -19)
<br />MONITORING PERIOD
<br />YEAR ...- DAY
<br />L J 1
<br />YEAR
<br />J
<br />MO
<br />U ")
<br />DAY
<br />(24 -25)
<br />T
<br />(REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.)
<br />003 A
<br />DISCHARGE NUMBER
<br />1(26-27) (28 -29) (30-31)
<br />OIL AND GREASE; SEE FOOTNOTE F/.
<br />- FINAL
<br />STORMWATER DISCHARGE
<br />pproved.
<br />o. 2040.0004
<br />Approval expires 6 -30 -91
<br />I .
<br />�fIH0R (SUBf WC) X NT,kS •
<br />NOTE: Read Instructions before completing this form.
<br />00073/900810 -1402
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