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PERMIitEE NAMElADORE55 (EiwYi F,eWylfaWErc.nm Und,.a0 <br />NAME TnAFYF.N "I ':I~•l;, I'/:. <br />ADDRESS Tit, E'FF.H :'.j :~.' <br />P.O. E~X 1+7 <br />FAaLm <br />LOCATION <br />n `1 ~I. L a• 14 L: .9DU'• 1~'.. :. f.~, Y~1~^', ~~: .. i. ._:{ <br />NATIONAL POLLUTANT DISCHMOE ELIMINATON SYSTEM INPDESI <br />DISCHARGE MONITORING REPORT lOMR1 <br />/I-161 l17-i 9) <br />Cc',~7~2115 (0? a <br />PERMIT NUMBER DISCHMGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ TO <br />170-I1/ 111-131 /1L751 !16171 119-191 /30311 <br />fosr Flu '*o <br />(SI'rF 1'a) <br />- - eT"AC <br />°*tiCs <br />Form Approved. <br />~ U R.~ A~ NYC fyO~t0004 <br />Approvelle>~rRe~ OS-31-98 <br />NOTE: Reed In~truNaAe before completlnp thle form. <br />PARAMETER 13 Qrd Onryl QUANTITY OR LOADING l~ drd Onlrl QUANTITY OR CONCENTRATION NO. FREGVENCY SAMPLE <br /> 11653) !54911 139-15I 1653 I5L9! OF <br />137-371 EX <br />MALrs~s TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS m:-e]l !54891 163701 <br />l ;I SAMPLE . ... .. ... ^•ir ;'-J :t C:lk^ ( ? 2~ / <br /> MEASUREMENT ~; ~ $ ~j ~ /~ ~'-J~TY <br />C~uL~ 1 0 U PERMIT '->:,.I.-~~ °~* r.,l~k4 v;:'. 4.5 - 4.1aaSa# 9,L+ FEYLY Ct7;ITt <br />~F'tLii4T i;°.,)SS YALI! REQUIREMENT :~V-'.~4 ;.~j:xY(!}ti~; MA.](]!+,I}R:. SU <br /> SAMPLE <br /> MEASUREMENT ' <br /> <br />.:PERMIT <br />~. .. - .. <br />.. <br />.... <br /> REQUIREMENT ~ ~ ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> ~'REQUIHEMENT <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 /> SAMPL£ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/i1TLE PRINCIPAL EXECUTNE OFFICER I LERTFY UNDER PENALTY Of lAW TNAT I HAVE PERSONALLY E%AMINED MD <br />AM fAMIUM W1TN THE WFORMATION SUBMITTED NEREIN; MD BASED ON TELEPHONE DATE <br /> MY INQUIRY OF TNOSE INDINOUALS IMMEDIATELY RESPONSIBLE fOq <br />OBTNNING THE INEORMATON <br />I BELIEVE THE SUBMITTED INFORMATION le <br />~ ` ~~ <br />W. CrUIfIOII Peters , <br />TRUE, ACCURATE MD LOMRETE. 1 AM AWME THAT TNERE MF <br />SIGNIRCMT PENALTIES FOR SUBMITTING FKSE INFORMATION <br />INCLWING ~ 970-824-4401 98 ] 27 <br /> , <br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 1B U.B.C. f 1001 MD 9] EIONATURE OF MtREt7PAL E7(ECUTNE <br /> U.S.C. 1 131 B. //Mrti. YIM 051M .sNha ,MY A%kW /11lI. Ip m i 10,000 <br />TYPED OR PRINTED .ndA'mot~,..r,FRa+rMYeAnr arMMrn(marrAr rMeYAVr.I OFFICER OR AUTHORRED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS ANO EAYLANAl1ON Oh ANT VIULAIIVNS INe/Y/YnC1 Ir/ef(eCllTenr901/e/ <br />.3:i r: f~'TnL idUti ii}li?.; NIi.L ,:E +AIVED, e1ND SET?LEAfLE 'iOCICI III']? AIICI}T FCF <=lOYk,?4t'fi Pi:F.CIP Y':ST- <br />cic:L (DUh:)~~ OF P.;OCF b.JUIR°d=;ai:i OkJ'n T.F. 3. PFk"1ITTg; ..".I!c_T 'lARF ALI FEAtrhAPl•r `!?.450KF.'t, TO n°G~iC' <br />v ,1+~ f •: Tw vrH ,• c r <br />EPA Form 3920-1 (08.96) Previous editions may be used. (REPL11CE5 EPA FORM T30 WHICH MAY NOT USE •) C 0 0 0 5 / S 71211-164 6 PAGE 1OF r <br />