|
PERMITTEE NAME/ADDRESS pr>VJr FrWyNwWfasum UD16.rmq
<br />NAME C1. - L ~ I -~' ._o
<br />,T ..
<br />ADDRESS CL..~ n: .,. .`~ Jo I
<br />FACarrv I. C 1 , - , , ~ i . „ e
<br />_ `., ~
<br />LOCATION
<br />NATIONAL POLLUTANT DISCNAROE ELIMINATON SYSTEM INPDESI
<br />DISCH~ R6 E MONITORING REPORT IDM91
<br />_ .. .. I. ~
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM ;'I (i/ 1 I TO ~~ -, [
<br />!3431/ 333-33/ !3436/ !36371 138-391 1343/1
<br />Form Approved. •I
<br />~ ~ ~ .~ , - J OMB No. 2040-0004
<br />ApproveCexpNee OS-31-98
<br />- .'i.:.L
<br />_ j ...
<br />NOTE: Rasd Instructlorr befaie compktinp this form.
<br />PARAMETER 13 Grd On/yl QUANTITY OR LOADING 14 Grd On/rl QUANTITY OR CONCENTRATION NO. N+EGUENCr SAMPLE
<br /> 116-53 1546/1 /39-451 !46531 1546// E%
<br />133-373 µALYSIS TYPE
<br /> AVERAGE' MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 161.6,11 /64681 /6870/
<br />? SAMPLE t : - ~ ~ ~ ~'•
<br /> MEASUREMENT
<br />GO.JU -- 7 PERMIT .. :':rv :F{ ',: 4''r ^1,: e ti ~.'~= ^el'.
<br />~ i',. . ,`F L ?lip
<br />
<br />. ~ r~ ~ - - , I
<br />REQUIREMENT
<br />Y t
<br />- ~
<br />y T r.,
<br />.I .
<br />.~(i'.i JSF _ .- ~ ~ - SAMPLE 1':: ?'::Y ': ~ r i~
<br /> MEASUREMENT
<br />L 1i '3r j I ( ~ PERMIT - . .. ::L:
<br />.. ~ . !~': » . , . . r` (, r .. r ~
<br />: ,
<br />
<br />-' /: U ~. .. ~: 7 - -
<br />REQUIREMENT .
<br />C: r V ~)
<br />._~ .. T,.I
<br />~ 17 Llr/
<br />, ~
<br />.,
<br />J '.. :. J ~ a . .. .. SAMPLE ... ,- .. +:.':::_ ' ~
<br /> MEASUREMENT
<br />I)~'JU~ 1 L ~ PERMIT »ztT :~; ..~ ;a :'/'~ °w'. '. - r:< jp ~ 'm-n ~~
<br />
<br />c ~ L .~ r. J ti . ~. 2 L ,) ~-
<br />REQUIREMENT
<br />~ ~
<br />-
<br />n is 'f ~, C` '. ~
<br />~: / -
<br />,
<br />.
<br />:LJ.o _: .. ,, C.: .~' SAMPLE w, .,.. ..- ...
<br />, _
<br />~
<br />~ I . MEASUREMENT ,tl
<br />i
<br />;
<br />(
<br />,
<br />:i (JCS. _- C' PERMIT :~~.: T.. .iL ?~"'~:i ..-. .,: r': - ...: .~ i '
<br />J 1~ (II REQUIREMENT ~)D
<br />PG
<br />" ~
<br />~ ~
<br />'~ ;i
<br />: r
<br />~+ - ..
<br />. L .,
<br />..
<br />. _,
<br />.
<br />. •
<br />.iJ!. .L'. _.I- t
<br />a SAMPLE i- •. +:• o;.~ / ~.
<br /> MEASUREMENT '
<br />
<br />., . ~ ~ :. ( PERMIT ry ... _ r: ;: ;: t. • ` ;::t .. ... "~~ ~ - :;r ~ i. (S : ' i i, . , . F .. I ,
<br />L ~ ~ - I REQUIREMENT '~. r: ~
<br />" ~
<br /> i :.~ . ~r
<br />) .'
<br />. SAMPLE .~ -r. ~ ~ ;:;.
<br />.-
<br />..
<br />- MEASUREMENT
<br />~
<br />I. _ , o .. PERMIT
<br />
<br />. .
<br />..
<br />
<br />, ~
<br />' C . .. _ _ - :~,~ ? -. ~ .. .. ~
<br />J1.. r :
<br />I ... -l
<br />~' . I I :: I _~ .... , .I - L / REQUIREMENT '- - - ' ~ - -- " .
<br /> SAMPLE
<br /> MEASUREMENT '
<br /> PERMIT
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT 1 HAVE PERSONALLY EXAMINED AND TELEPHONE DATE
<br /> AM FAMILIAfl WITH THE INFO RMATION SUBMITTED HEREIN; AND eASED ON
<br />-~
<br />J
<br />[
<br />' ~ ~-~
<br />= /' MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONABLE FOR
<br />OBTAINING THE INFORMATION
<br />I BELIEVE THE SUBMITTED INFORMATION IS
<br />/
<br />~ ~ -
<br />,
<br />;
<br />L
<br />_ -_ , _
<br />'
<br />'
<br />
<br />' ~/ TRUE, ACCUMTE AND COMRETE. I AM AWARE THAT THERE ARE
<br />SIGNIFCANT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING ~/ ~
<br />~
<br />i -
<br />/~ ."I rr r' ':^ ~ ,
<br />TXE POSSIBILITY OF RNE AND IMP111SONMENT. SEE 18 U.S.C. E 1001 AND ]] BIONATURE OF PRINCIPAL E%ECUTIVE /r'' „' J ' I~ /
<br />~ ~ ~
<br />• I ~ ~~ /
<br /> u.s.c. F t at s. lan/rls uvr dwr mrrmr• n,.r L+rA.w 6rNr w ro J 10,000 AREA
<br />TYPED OR PRINTED rWrmvirwninpionwnr of fwnrwn smmNaW6y~l OFFICER OR AUTHORIZED AOENi CODE NUMBER YEAR MO DAY
<br />ODMMGN I5 ANV urL.nnn I wn ur nnr YwLn I Iuna rneTerence sn anacnmenrs nere/
<br />o - 1
<br />' e..o _a .. T-~o o _. -.. ... ~. - i - 1 -7- .e
<br />EPA Form 3320-1 108.951 Previous editions mey ba used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 , I, . / _ _ - PAGE , OF
<br />
|