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rYHMlI Itt NAME/ADUF pkLd. FaclOry N.w/Lonum dD~..m.) <br />NAME L:OI,')ftY.. ~~O+. r. COMPAf1Y L. P. <br />ADDRESS COL'J4YS) :1I "I}: <br />S/3L S1'ATI? 11(•:IINAY 13 <br />NATIONAL POLLUTMT D' 'ROE ELIMINATION SYSTFM INPOESI Form Appr <br />. DISCHARGE I <br />1-761 TORINO REPORT IDMR) <br />77-I9 <br />P•,. T~ Y I,0^ ll~y _ <br />PORFl 'i OAp fa a plre OOA <br /> ~a fI IIR NH) 12345 <br />PERMIT NUMBER DISCHMDENUMBER F <br />FI <br /> - <br />NA7. <br />`1 ;:c;nr:R CO U1641 MONITORING PERIOD HT!IOR <br />~A CILI7Y <br />YEAR MO DAY YEAR MO DAY <br />LOCATION -- <br />FROM I TO c (1 D ''"` Nn I~Ti(:{{{{AR!'F II '•°~~°` <br />`NOTE: Read In~trilcllone ~elor~ completlnp thle form <br />. <br />l1P3I1 !11.131 !14151 !16171 !19.191 l36JIl <br />PARAMETER 1 3 G/d Onlyl QUANTITY OR LOADING q G/d Onlyl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE <br /> 46-631 54-61 (39-15 (46-63 154-61 of <br />131 371 EX Mursls TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ( s~.e.u 164661 169-701 <br />.)II, ANI~ ,: ii F'.4~~' SAMPLE #rp ~#,? ~ ( )I!) t,, o{r#-.`•=F <br />.~ <br />~.:'.::tfF:;: :: {::t:; :t:;: <br /> <br />~ O ID <br /> <br />~~ <br /> <br />~ <br /> MEASUREMENT , o ISUgI <br />V I S U A L . <br /> <br />HlaUuh 1 ll I) PERMIT.:..:.. <br />'.~. .. ~.:.... ~. .. <br />~~,...•~,•ktT#.~..' <br />0.:..::~,~:..:.~':.:..~~~~. ~~~~ <br />F.S=1 ,. ... <br />:~,}.~I~t~ir:~.~'~~. <br />~..~::-i~i;~:ti# <br />~T~-`:~~. <br />~.t:;:~><it'c::~:' <br />',.~~. <br />;:~.. <br />:': ~: <br />.~ i <br />FF.KLY <br />ISIIAf <br />. <br />. ~ :~- <br />. REQUIREMENT. . <br />.. ~. <br />... .. <br />.::.. ~::':.:' .:.. ...... ... <br />........ , <br />.... . <br />F <br />I : <br />7n <br />r V I : . <br />. ... <br />.Y:.:.,. .. <br /> SAMPLE <br /> MEASUREMENT <br /> ~' ~ ..:.. <br /> .REQUIREMENT. ..... ....:, ~ ~ ~ ~~ ~ ~ . <br /> SAMPLE <br /> MEASUREMENT <br /> <br />~~PERMIT.: ~.:, <br />.......~.: .. <br />.: ~... ... <br />~ ;. .:. <br />...: :. ..:~ <br />: <br />. <br />~:... <br />~ <br />:~.:~: ~:: ~.: '~:~ <br /> ~REQUIREMENT~ . <br />: <br />. <br />~: <br />.:.:. <br /> SAMPLE <br /> MEASUREMENT <br /> .....:PERMIT ..: ...:....:..::........:. ..:...: .. ..... <br />.: ... <br /> REQUIREMENT ::.:..;: ::, ::: .....: ..:::.:: ::::::::.:.. .::.:::.: <br /> SAMPLE <br /> MEASUREMENT <br /> R. <br /> <br />.R.EQUIREMENT~. <br />~~:~~.:'. '..~';: ..::::.:..~~.;~ <br />.~:~.~. ~.: :':..~... ~:.:... : . <br />.. .. .. <br />.. <br /> SAMPLE <br /> MEASUREMENT <br /> .. .. <br />PERMIT ~ . .. <br />.. ... .....:. .. <br />...:.:.....:... <br />' <br />~ .. <br />~ <br />. <br /> REDUIREMENT. ~ .....:..:.........:.....:.. ~ <br />:.;..... . . <br /> SAMPLE <br /> MEASUREMENT <br /> .:..PERMIT:....' ......::. :::...: :...:.:...: ..... <br /> REQUIREMENT:.: ~ ;;.:;~~~::~~:t.:::.:..::...:.; .~:..::~~,~:.~~::..`:.:.:.:.::~:.:~::.: . ... <br />:.. ......: ... <br />,. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIfY UNDER PENALTY OF <br />AM fAMILIM WITH THE INFO LAW THAT I HAVE PERSONALLY ERAMINED ANO <br />RMATION BUBMITTfO MFflEIN <br />MD BARED ON TELEPHONE DATE <br /> ; <br />MY INOV10.Y OF THOSE DEDIVIDUALB IMMEDIATELY RESPONS[BLE FOR <br /> OBTNNINO THE INfORMATION, I BELIEVE THE BUBMITTED INFORMATION IS <br /> TRUE, ACCUMTF MO COMPLETE. I AM AWME THAT THERE Mf <br /> BIONIFICMT PENALTIES FOR BUBMITTIHO FAIRE INFORMATION <br />INCLUOINO <br /> <br />'' ll'_ <br />n <br />D 1" <br />l <br />' <br />, <br />THE POBSIBIUTY OF FlNE MD IMPRISONMENT <br />SEE 1B U <br />B <br />C <br />1 11101 MD 73 <br /> <br />- QQ <br />8 <br /> <br />I <br />q <br />, <br />T( <br />.1 . <br />. <br />. <br />. <br />U <br />C <br />~ <br />~ <br />~ 61 NATURE OF PRINCIPAL EXECUTIVE 00 ! <br /> `~~ ~' ~ 1o f ro'e0° <br />' <br />d~ <br />u.~ <br />M <br />r <br />~'~ 1ONh' ~r AREA <br />TYPED OR VRINTED , <br />, <br />I <br />a <br />•, <br />, <br />pl+amwnt olMMnn4monN. uM4vwa1 OFFICER OR Al1THORIZED AGENT <br />CODE NUMBER YEAR MO DAY <br />c.vmmnv~nn.+cnrcnnn nvn yr nn, vn+cn nvno lne, steno eu euecnmsnu nets/ <br />Sr;'C'CLh'dHLr: :~oLInS (.IUTI' APf'LLBS ONLY IF <=.10=YR, 2'a-l[R pAP.CT.I? EVENT IS CLATt7FD. TF rL4CU APPROVI?D RY <br />4QCU, 1'55 [:':7!1 LIPIITS IVII,L NOT UF, APPLIF,D TO REP02TRD 9EASURFNRNTS--S F. P. T.R.].A, pG 4 A;JD I.Fl.1D, PG 6, <br />EPA Form 3320-1 108-951 Previous editions mey be ueod. IREPLACEB EPA FORM TAO WHICH MAY HOT BE USED.) PAGE Of <br />nnnr r .nn n,. ~. - - <br />..-. .... .-....~_r--~ ~ .. - <br />