Laserfiche WebLink
ADDRESS— 7-•—:�~.1—= r_LJ�_LL1—L r' 1 L <br /> PERMIT 4IVMBER -.-CHARGE NUMBER <br /> ----�r= -- ——————————————— MONITORING PERIOD <br /> f�l�Etf.AIL--------------------- YEAR MO D YEAR MO DAY <br /> LOCATION ----- FROM Ah r• 1 AYTO fir, :r <br /> (20.21) (11 (16 ) (18.19) (30-11) NOTE: Read Instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (I Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (I6-33) (3e-61) (18-43) (46-33) NO. FREQUENCY SAMPLI <br /> (31.17) EX ANwLOrF <br /> >< -I- TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITE 61-63) (Ae 68) (69-70) <br /> SAMPLE <br /> FL (EFF---.'E , T! MEASUREMENT NO DISC RGE * # w <br /> PERMIT G(� <br /> .1 5 REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> (FFFLOE•' T) PERMIT L .'k 'G/L <br /> ( Q I REQUIREMENT <br /> SAMPLE <br /> I i'I�I• - T T A L MEASUREMENT ' <br /> PERMIT �.a/ vG/L <br /> 5 REQUIREMENT * * * - r <br /> SAMPLE <br /> p d$FIELD MEASUREMENT * * <br /> 1 PERMIT _ <br /> REQUIREMENT L <br /> SAMPLE <br /> r. IL K G,<EHSE MEASUREMENT <br /> vISW,L PERMIT MG L <br /> A I, J 2 REQUIREMENT <br /> SAMPLE <br /> GUCTI�,ITr (�/,• � MEASUREMENT <br /> -(t;s (EFFLI,EaT) PERMIT <br /> 4 REQUIREMENT * !1 * rr * tt r w !r * * * * tt * s <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELKPMONE D A T E <br /> APIO AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> y� ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> Jay rlCdnick OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMATION \\ r pCCC A <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG G..J D4 25 <br /> Hydrogeologist NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING v'V <br /> 303 337-5903 <br /> THE ►OSSISILITY OF FOR AND IMPRISONMENT SEE IB USC 1 1001 AND SIGN RE OF PRINCIPAL EXEC TIVE <br /> 33 US (1 19 /Prno/twe wdrr thewUamtn mar Inrlldr hoer rp Iu IIO"" <br /> TYPED OR PRINTED ardv✓menmumrmpnwnmrntr./M/llwn6mnntheand5.rorrl O ICER OR AUTHORIZED AGENT NUMBER YEAR MO •DA` <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> IF U CCCUPREu Dim I` G To)IS REPCPTIr G PE:; IC.:' KEPCPT N,,..(] JISCrIARGEM <br /> t t <br /> EPA Form 332_-- (Rev. 10.79)PREVIOUs EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> UNTIL SUPPLY 19 EXHAUSTED <br />