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N A A11F__ 1 y_ '. f C- �/_1- Iy��/y_y(y yI-i CyL"i yI -!t I_—— (17.19) F sires 2-29-84 <br /> ADOREBs_ _-A/�X/OWXXX/1/�/�/1/�/1/�A/�/�xXxxxxxxxxx <br /> �(— PERMIT NUMBER .,.CHARGE NUMBER <br /> XLU�300 L.u[Y`aull`e, FlacLstaff� NZ_ MONITORING PERIOD <br /> -Inel� -----------160OL_ YEAR MO DAY-1 YEAR MO DAY <br /> FROM - _ _ TO I.•, <br /> (20-21) (22.23) (24-23) (26 ) (28.29) (30-31) NOTE: Read Instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (I Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-33) (54-61) (38-5) (46-53) (5I-61) NO. FREQOU` TYPE <br /> NCY SAMPLE <br /> EX <br /> (31-37) ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 6163) (61-48) (69-70) <br /> SAMPLMEASUREMENT No Discharge <br /> F L�J;- (F F F L:I;..� T) <br /> PERMIT U Le <br /> 51;05 ) REQUIREMENT * 'lC 'r CT <br /> SAMPLE <br /> SUL108 , TLIT4L SU-S P MEASUREMENT * * yr <br /> (EFFLi1E;4T ) PERMIT �;/ G/L <br /> il •)531) REQUIREMENT 35 73; 1/30 1; <br /> SAMPLE <br /> I-10IN9T0TAL MEASUREMENT <br /> PERMIT L5/n <br /> :, 10 4 S REQUIREMENT * ac .} * .�, ;. �• 3 7•7 Z U I711 <br /> SAMPLE <br /> Pr aLU MEASUREMENT <br /> I <br /> 11 PERMIT F� `'Ill <br /> .) 4 11 REQUIREMENT �' 'jC i!` 'k ,�{ '�' :�' 9( L". 5 )� it aM• 7 1. �./3 U W•, <br /> SAMPLE <br /> OIL Gi�EASE MEASUREMENT * * t * * * k <br /> VISUAL PERMIT <br /> A v U 0 REQUIREMENT <br /> SAMPLE <br /> M,iDUCTIVITY MEASUREMENT * t. <br /> TDS (EFFLUE',T) PERMIT <br /> 7^41(.;,r REQUIREMENT ,>s �r 7 r; k is k ►Y vY tt it )tr Kr # tk 1t 1/9 G 1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I NAVE PERSONALLY EXAMINED /� r TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED +IVAV/ <br /> H. Theodore Smith ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> Hydrologist IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG 1 <br /> NIF$CANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 46'USC 1 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE 602 774-5253 86 07 24 <br /> 33USC 11319 /Penolbn under three rcatubr n$av Include finer up to 11u IMM$ <br /> TYPED OR PRINTED nnd'ur manor urn lmprnonmrnt.d he t—n 6_Ih F and 5 v.or..) OFFICER OR AUTHORIZED AGENT A NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Rf1erence ail a(luchmerlo here) (� <br /> IF :A) 1:ISC`::RGE C'CCL ti!NE% ���-I �I 'G T�1IS ?iEPGrrTI•' G Pr R IU'7 /zEPG'RT „ >•:G OISCh;%RGE" <br /> U <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 /> I INTII PIIPot-V 1• PrMAIIRTI!n <br />