WQ0007521_GW-59A Compliance Report Form_20231220

GW-59A COMPLIANCE REPORT FORM Permit #—" O 00 7S.1
(Submit one each monitoring period with GW-59 forms.)
Enter date monitoring results were due. ( 12�) Will this monitoring report (GW-59 and GW-59A) YES
be submitted after the established due date?
2 Was any required information missing on the GW-59 report forms? YES NO
IF the answer to question 1 or 2 is "YES", list in the space provided below the well identification number(s) and
explain the problems encountered in obtaining the required information.
3
4
Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing
identification plate, area overgrown, etc.)? If the answer is "Yes", contact the Regional Office for guidance.
Are any monitored constituents equal to or above the established standards?
if the answer to question 4 is "NO", skip to section 8.
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s)
exceeding standards in the space provided below:
YES I f NO
YES
5 For the constituents identified in question 4 above, have standards been exceeded previously for the YES j NO
same constituent(s) in the same well(s) in the last two years?
C
It the answer to question 5 is "NO", skip to section 8.
If the answer to question 5 is "YES"' list in the space provided below, each well with constituent(s) exceeding
standards, concentration(s) reported, and sample collection date for each occurrence (for the last two years).
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
j If the answer is "YES", a groundwater quality problem may be occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells may be improperly
located; contact the Regional Office.
YES I NO
+Is the permittee implementing previously approvedactions required by the Division involving this YES NO
roundwater quality problem?
If the answer to question 7 is "YES", describe those actions in the space provided below.
If the answer to question 7 is "NO" contact the Regional Office within 90 days; an evaluation may be
required to determine the impact the waste disposal system is having at the review and compliance
boundaries surroundinq this facility. Failure to do so may sub"ect the permittee to a Notice of Violation
fines, and/or penalties.
g The person completing this portion (GW--59A) of the monitoring report should sign below and submit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
I hereby acknowledge that the above information was evaluated and the information submitted in this
report (Compliance Report GIN ) is true and c plete to the best of my knowledge.
Sig ature of Permittee (o uthorizid Agent) Date
GNY-59A 12/8/2003

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