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td ? <br />PERMITTEE NAAIElAISDRE65 peelJ.Fs19yNA~/!xm/a yDleewj <br />NAME! <br />ADDRESS ,.: _ ~ ~" ~ ~ ~ - <br />FACILITY <br />LocAnoN . <br />• <br /> <br />-~ <br />NATIONN. POLLUTANT g5CHM0E ELMINATON SYSTEM li~i•ic5• <br />DISCNAROE MONRORINQ REPORT fOMRI <br />17-16 I7-19 <br />l PERMIY NUMAER DOJCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM I - I TO , t <br />tlQ]11 !]]-931 tl4]51 /1R-]71 !]R-991 !30.311 <br />Form ApproveG. <br />OMB No. 2040-000x, <br />' ~ - ~~ T Approval ezpiree 05-31-98 <br />NOTE: ~Ried Irietrucflatr M1on~ oom~letinp this fam. <br />PARAMETER l3 Cnd OMYI QUANTRY OR LOADING l1 Grd OnlYl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> f1fr53 !54-61 !3B-t51 ab 161-61 DF <br />l31-371 <br /> <br />AVERAGE <br /> <br />MAXIMUM <br /> <br />UNITS <br /> <br />MINIMUM <br /> <br />AVERAGE <br /> <br />MAXIMUM <br /> <br />UNITS EX <br /> <br />!s9-s9l <br />NIN-YA5 <br />l61-6e1 TYPE <br /> <br />l6s-7ol <br /> SAMPLE <br />~ <br />- ' ~ <br />~ t <br />~ <br /> MEASUREMENT <br />.: ,.. <br /> PERMIT <br />~ <br />., REQUIREMENT .. ,. r,,., : p ^,:J( . -' iw... L: y: <br />~ ,...~ 0:6t ::'{::~>~.. ... ' t~ r• 0. ~. • 1 . l[ n <br /> r *i~ ^+ <br /> SAMPLE ~~ <br />• MEASUREMENT <br />~. <br />/ . %~ ~ <br /> PERMIT ~ ~~ <br /> REQUIREMENT ~ ~ ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ ~ ~ ~ ~ ~ - - <br /> REQUTAEMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ~~ PERMIT <br /> .REQUIREMENT <br /> SAMPLE <br />. MEASUREMENT <br /> PERMIT.. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~ ~ ~ ~~ <br />NAME/TRLE PRINgPAL EXECUTIVE OFFlCER I CERTI <br />AM FA FY UNDER PENALTY OF UW THAT 1 HAVE PERNNALLY EAAMINED AND <br />MILIAR !NTH THE INFORMATION SUBMITTED HEREIN; AND BASED ON - f~ - <br />- - TELEPHONE DATE <br /> <br />~ <br />~ MY INQUIRY OF TN05E INOINDUALS IMMEDIATELY RESPONSBLE FOR <br />rte. ' <br />' ` ~ 1 ~ q`) ! OBTNNING THE INFOIIMA710N, I BELIEVE THE SUBMITTED INFORMATON IS ' <br />~ <br />) TRUE, ACCUMTE AND COMRETE. 1 AM AWARE THAT THERE ME <br />SIGNIFICANT PENKTIES FOR SUBMITTING FALSE INFORMATON <br />INCLUDING /I , <br />' <br />~ <br />( f( - u <~ 6 ~ , <br />THE P0591BIDTY OF RNE AND IM%YSONMENT. SEE 1B V.S.C. 1 1001 AND 93 ~ <br />610NATURE OF PIIMCBAL E7EECUTNE r .~ ~ -/ _ - <br />- <br />r' ~' <br />' ' -l ; <br /> u.5.c, f t sIB. lMAeY• nwr qea meme mer InrANe R+.e W ro F Io,000 <br />TYPED OR PRINTED end or nMeinun inprleonnwN a/Mereen emm/Aa eAd6Yere.l OFFICER OR AUT)fORIZED AGENT CODE NUMBER YEAR MO DAV <br />COMMON IS ANU CAYLANAIIDN OF ANT VIVLAIIVNS IIrBrB/BOOB a//IRBCOTB/1E3 /IYl6/ <br />. ~ ~ _. .. ~ ~.T' ~ .. 1.. ~ ,. -'i /~~ • ~~{ r -. a- • ~' 1. r .. <br />• <br />EPAforlrf 3320.1 (8-96) Previow editiohe m y'DS ueed. ~ / 1 CES~EPA FOR T 0 CH MAY NOT BE USED.1 ~ ` • / / - - • / • PAGE OF <br />/ "'t _. , <br />