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----- --_---- —j---- � ,� �� <br /> - ,11 T� C V PERMIT BER DIaC HARGE NUMBER <br /> _--- ------------------- MONITORING PERIOD <br /> EA C"LT—Y————————————————————— YEAR MO DAY YEAR MO DAY <br /> LOCATION --- FROM „�. TO -7 <br /> --------------------— <br /> (/o• 1) (/2 J) (/4- s) (.'� ) ?.M-29) (J0-JJ) NOTE: Read instructions before completing this loan. <br /> (J Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-3J) (54-61) (38-43) (46-3J) NO. FREOVENCY SAMPLI <br /> OF <br /> (32-17) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITY MINIMUM AVERAGE MAXIMUM UNITS 61.6J) (64-8) (69-70) <br /> SAMPLE <br /> LC' (E FFLIIE-T I MEASUREMENT NO DISCILARGE * * # * * w <br /> PERMIT G, <br /> REQUIREMENT * * * * * * * * * * * * * * Tt k * >t It ]I/ f/3(� C, <br /> SAMPLE <br /> I1;Ss TCT-L sP MEASUREMENT <br /> '1 * * * -- <br /> (EFFLUiAT) PERMIT Lr/ .5G/L <br /> 5 3 •, REovIRwwT * * * * * * * * * * 3 5 7 0 f/3 G <br /> SAMPLE <br /> I".!71, •TC,TAL MEASUREMENT <br /> PERMir La/r r;G/L <br /> 1 ,�,►c REQ�IRwwT * * * w * * rr ,t rr * * 3 5 7 0 1/3 0 6 f <br /> SAMPLE <br /> h1OFIELL, MEASUREMENT ` <br /> PERMIT - s U <br /> 1 4+:,, REQUIREMENT * * +Y * * * * 6.5 >r * * w 9 0 I/3 0 GF <br /> I <br /> SAMPLE <br /> IL K GREA5E MEASUREMENT <br /> VISUAL PERMIT GIL <br /> 0 ,2 10 1/3 0 V] <br /> SAMPLE <br /> 1LUCTIVITY K/:: MEASUREMENT * * * * + } * w <br /> 1 - 0 (EFFLUEI;T) PERMIT <br /> U 11 -. REQVIREM0" 1/90 GF <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T [ <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ON My <br /> INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> Jay Mednick OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> r," <br /> Nydrogeologist NIFICANT PENALTIES FOR SUBMIrTING FALSE INFORMATION INCLUDING 03 337-5903 86 04 5 <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 1 1p01 AND BIQN URE OF PRINCIPAL EXECUTIVE <br /> 33 U S C 1 13 19 (PIMlt41 under thew statute. near Include /Inn up to 110IMMl <br /> TYPED OR PRINTED and nr maXlmunr ItnPrIHV.neent uu(Mlu-wn 6 month.and 3--I OFFICER OR AUTHORIZED AGENT CODE <br /> NUMBER YEAR MO DAB <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Re/errnce all attuchments here) <br /> IF . t.ISC,44PGE ICCL'RIlEU GURI :G THIS REPCIPTI-G PERIOU REpQRT —0 uISCHAPGEM <br /> 1 1 <br /> EPA Form 3320.1 (Rev. 10.79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> UNTIL SUPPLY 16 EXHAUSTED <br />