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~} ¢} ' <br />A"ERLMi`h~~ FIAI~~IAODRESS ped,/.P.emnNw/Ta,ua,Volar...q <br />NAME =.,^: - .. , <br />i <br />ADDRESS ~. ,, .. _ ~. _ . - <br />f~ • J • ' , <br />.~ ~ <br />LOCATION ~-~ ~~~ ` <br />. III r: <br />NATONK POLLUTMT D19CNMOE ELIMINATION SYSTEM INPDE$l FOET APPIOVed. <br />DISCHARGE MONITOPINO REPORT IDMRI . ~ -OMB, No.. 2040-0004; <br />I-l6 17-19I '~! ' - ~ <br />_ ~ , ~ T ; „ r _ ~ _~ ~~ - r ~ APProvey ezgires OS31-98 <br />PERMIT NUMBER DISCHMGE NUMBER ~ I I ~ l ~ <br />L ~ i ,. <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />I I__I <br />FROM ~~ i .J '~ I' TO ;.~ .,~ .. ., .:. ,..:. <br />/~mn nzaal /,uRI rneun roQ_POl rar>_oa ~ NOTE: Reed InetrucTlDr. bNon DomDATInO thle fwm. <br />PARAMETER 13 Grd OnIYI QUANTITY OR LOADING 11 Grd Ontyl QUANTITY OR CONCENTRATION NO. ~EGU°!~' SAMPLE <br />l~J7/ 4653 !5667 l3B-16 !166 151-81 OF <br /> EX <br />MKrzs TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rt2-091 (61-681 !5&701 <br /> <br />i .. <br />E ~ ~ <br />,~ ; r = <br />~ <br />.. <br />~ ! <br />.. :.. <br />:.. <br />. <br />. MEASUREMENT <br />i ::,,. <br />A i <br />.q .ul. L :) PERMIT , re;3 r;:::=~ 'u PSI is `[ ,. '.,1 >v:}: r,•,::v .~t:;;tis ".x ;:<~;: ;a; <br />~ <br />,~ ~/~"Y tF. i'i Ri <br /> REQUIREMENT ~ ~ <br /> <br /> SAMPLE <br /> MEASUREMENT 1 <br />-YI ~ I ~ <br />. I 4~~ 7~' <br /> ~~~. PERMIT~~~ ~ ~ ~ ~ ~. .. <br /> ~:REQl11REMENT ~ ~ .. <br /> SAMPLE <br /> MEASUREMENT <br /> ~: P..ERMIT <br /> ~REnl11REMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> - <br /> SAMPLE <br /> MEASUREMENT AUG 3 ~ 1 98 <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE 8 GEOLO <br /> MEASUREMENT <br /> <br />• PERM17 . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT. <br />NAMERITLE PRINCIPAL EXECUTIVE OFFlCER I CERTIFY UNDER PENKTY OF uW THAT 1 HAVE PERSONKLY E%ANnNED MD <br />AM FAMILIM WITH THE INFORMATION SUBMITTED HEREIN <br />MD BASFD ON ' .- ~ ~-~ <br />' TELEPHONE DATE <br /> ; <br />MY INQUIRY OF THOSE INDIVIDUKS IMMEDIATELY RESPONSIBLE FOR ~ / <br />~ <br />11 <br />_ 1 t I t - 1 ~ I I C 1• OSTNNINO THE INFORMATON, 19EilEVE THE SUBMITTED INFORMATION IS ; <br /> TRUE, ACCUMTE MD COMPLETE. I AM AWME THAT THERE ME <br />SIGNIFICMT PENKTIES FOR SUBMITTING FKSE INFORMATION <br />INCLWING / /~~ <br />~' <br />~ . , <br />THE POSSIBILITY OF RNE MD IMMUSONMENT. SEE to V.S.C. 1 1001 MD 93 / ~ ~ - ~ - ~ <br /> <br />s <br />c <br />t tats <br />IPwrrtl., <br />U <br />nM d <br />m <br />m <br />i <br />pl <br />9 <br />s roa0 <br />SIGNATURE Of PRINCIPAL E%ECUTNE _ <br />~ <br /> <br />TYPED OR PRINTED . <br />. <br />. <br />. <br />r.w <br />u <br />u <br />c <br />, .I.r <br />, <br />n., w ro <br />,nsnm„Ieun Erl <br />H,anrwnt e/bfwwr <br />W rM6 <br />E <br />OFFl <br />R AREA <br />NUMBER <br /> l <br />man <br />P <br />r,ra/ OR AUTHOpIZED AGENT <br />CE CODE YEAR MO DAV <br />I.UMMCn IA nnv cnr~nnn nvn yr nn. •~u~n nw,a ln~.Ylence sn snsrnmonl.Y note/ <br />~ T <br />EP4CFoirIP X320-T ~ ~ 1 Previous editions iney'6e used. ~ ~ ' REPLACES'Ef+A FtiTi T40 WNICH MAY NOT BE USED.) - - / _ I PAGE OF <br />