|
ERMITTEE NAMEIADD' ''Onr•,d. F.u6ry N•n/Lacanm yDlp rmO
<br />VA ME CO1.U R'f ~U.n I. COf1PANY L•P•
<br />ADDRESSC0I,UYYO itLNF.
<br />57.11 STA.T.'i HIr,HIVAY 13
<br />NATIONAL POLIUTAHT [`
<br />H WOE ELIMINATION SYSTEM /INPDESI
<br />O
<br />E
<br />O
<br />T DAfR Form Appr
<br />DISC
<br />ARGE
<br />2-IS) P
<br />IT
<br />RINO R
<br />R
<br />I
<br />n-IS
<br />STREET PC f;ULCII Q~
<br />TOQ
<br />~'~P~` ~p~d54~t ~3s
<br />A
<br />l
<br /> (SlII1R N11) p
<br />rovele)cp
<br />u~
<br />L 1
<br />PERMIT NUMBER DISCHARDE NUMBER F- F I N A I.
<br />it t; (;!t r Ic t:U x116 41 MONITORING PERIOD [1 L H U t? '.
<br />~CrILITY YEAR MO DAY YEAR MO DAY _
<br />IcanoN ~ I~I trl~.aT`.,or.l ~aw.•la\ \ `~dY+0. t,( FROM 99 U'1 U]. TG 913 OG 30 "r. Nn DI rHARf I? ~ ) .k,
<br />µ
<br />NOTE: Read Inelnlctlone before compleElnp Ehle form.
<br />_ !2621) !22.23) !26261 116-Z71 128-29) 1303F1
<br />PARAMETER ! 3 Grd On/yl QUANTITY OR LOADING l ~ Grd Onlrl QUANTITY OR CONCENTRATION ND, FREQUENCY SAMPLE
<br /> IE63 566f 138Jb 4G63 6661
<br />EX of
<br />!32.371
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS 1
<br />02~es1 ANUrsIS
<br />ls66s1 TYPE
<br />lb5-101
<br />
<br />Il SAMPLE A
<br />#####rA ~ ##Sry'k iL %k yY #:k#
<br />8
<br />S
<br />( ] ?) I .
<br /> MEASUREMENT 1 , ~ • ~ >°{ 10
<br />
<br />'U'lU0 1 l1 U
<br />P.ERMIT:.:.i
<br />::'.'.%X#nQ,~tt.;.... ,. w .,.
<br />?'?.•.'..
<br />!.:
<br />~:~~~±'
<br />^'~`r
<br />615
<br />:;::'.::...'".:::.:
<br />.:::.####:}#:..
<br />~'.n.::.:;'..;:.':..;.
<br />!
<br />EQKL
<br />Y
<br />+'RAFJ
<br />.h'FLUI:`I'T Il!1`.;t REQUIREMENT : ...::...:..::::..::: .
<br />.
<br />.:.:..:.:•..:,:..... .
<br />..
<br />. .
<br />Il)I.LD:i, 'l'!)TP.L SAMPLE '.:Yx#R# ####i:# #:k#### II
<br />I
<br />~
<br />Y
<br />b
<br />( 19) D
<br />/9
<br />. IJ i I' c ti S) fa) MEASUREMENT D L9 0 G
<br />IU~JU 1 U U PERMIT:..::.. :.:y~#~:#.?X.:.::• :.:::'r~:%#.r:'k::. #~~k (`"''k~^'~':
<br />:: 3.`~:.':' .:':::::::: :~:~1.,.... '.:%.::.:'.-... r NCF/ . ,AAB
<br />:F"r l.Ur'll'f i; IfUSS YA LII I. REgUIREMENT~
<br />~ :::~~`~~:;:~.~::'::~~.;,'::.::. ~~.::~;.'. _~~~~~::'..::::..:~~~ #Y:R .
<br />~ ~ .r..
<br />~ :;
<br />~ C ..
<br />il)L1 Uti, .i%T'l'1. F'At1LF; SAMPLE ~=##^r## ##ir 5`•## #####•
<br /># #%:•',~
<br />##K=
<br />~~
<br />5 ( zi)
<br />~
<br />4
<br />/~ /+
<br />
<br />MEASUREMENT
<br />. l71
<br />)US4S 1 U U :'PERMIT rt~:4>'t L3r h'.::::.
<br />..:.. ..
<br />:.. :.'::t+.#?X.~iV fc Y=`•: (: +I:#/kft ~F: . .' ;fc 9F #t•~F G:•:: ~).•',r7:: :
<br />::::'::::: [ HCE/ ~RAR
<br />
<br />t t L IJ h r'[ ~ 110`i ;> V A [. IJ C
<br />REQUIREMENT .
<br />. .
<br />
<br />,. <
<br />)I1. ANU :; ;{t'A'; F' SAMPLE
<br />MEASUREMENT %k##### ###r,; ',::t :;;:k r;:;Y':# =k%;##f,::.`•
<br />
<br />~/p1
<br />( , U)
<br />
<br />N~A
<br />
<br />N/A
<br />
<br />N~A
<br />I t• r• 1
<br />~I[h:J1 ,~('I'Ii-~!(AV MF'L'.,
<br />
<br />)U15G 1 U U
<br />PERMIT::':.:.'
<br />::##~.~:~#::'..::
<br />::::lk#G~~#•`,•.~
<br />:k~:.g
<br />~.tA#Tk:?tF..;::.
<br />:'.:.##~#.i;l%L..'. ,.
<br />.'l.'Q..:``':i'::. ':.:
<br />ONTIH
<br />+RAFI
<br />r
<br />:t'F'l.Ul<4f ~fi~)';J VAI.IIF REQUIREMENT ..: ;. ...:: ~: ~.:.:: ;:~ .:
<br />- ::.::::.:::::: ..:...:...:.: :.. .:~.. ..
<br />.:::::.>•.::.,.,:...: :k :k?R
<br />;:.::
<br />'.i. ri':':tTA..
<br />11 C, 1.
<br />G.N
<br />.Ni)!r, 'I.'0'rAL SAMPLE
<br />URE
<br />ENT
<br />E ~k#?~;-# ;#;..•^•#~k t~#'F,YA'I
<br />77b
<br />~Z
<br />!(9 ( 19)
<br />O
<br />90
<br />G
<br />(71 ;~ F'F) M
<br />AS
<br />M .
<br />1 .lUll~ L U r) ~~~... PERMIT:~.~~'
<br />
<br />~ ~:~.:.#:~4R.?ti.'T~:::. ~...:
<br />
<br />~
<br />~ ':~::..~..#..')`~?;kr~. :.....
<br />:.:: ~~. ~.fT :,`•:k.##.~:'::
<br />3:5::4::.::::':;2.;.
<br />7:::0.:.:::;', ::'
<br />[
<br />N.G>~/.
<br />,RAB
<br />:il'LUt:N'L' 1)I(7:;~ VAL.UF. ~REQUIREMENT .;:.
<br />.:::;~.:~:"~.:~.~
<br />: ~.:<,...........
<br />#;~: is ~~.~..:..::.:~~.~~. ~~
<br />0 A"::`AYG: .. ..:.
<br />..T i .:: M..
<br />tl(: I.
<br />0 '
<br />'Li)W, Id CL)NDUC!' 0$ SAMPLE
<br />MEASUREMENT ~y
<br />'~¢ ~'~~
<br />131 ( 03) ',:'.+#',::.`.# ##3.',:'}'.a #'~#~#:` N
<br />/A 1~
<br />~~1
<br />xns~art
<br />Cllliil '1'ctl',ATHrnT PL11N . 0
<br />_,UU~U 1 U (I .: PERNIIT~: ~~.~. P..T IO N:A~L~~.:; ~~.:~~s~~REPORT ~~~ ...~k.AF#?l. Y~~.. ,. `:
<br />:.. ;;=k=krt~>"".t^:~ ..~. ~:~~.;:~;t~~>k:t t:~~ : :k;: ... ~R
<br />l!If.L: Y NSTAN
<br />~
<br />',i'rF1.U8~1P ;RO.iS YAhII
<br />~ }REQUIREMENT: :
<br />::jUDA;:.AVG.. :DAIJ:Y HX. MGD . . .
<br />I;UL11)~, 't'L)Tal. SAMPLE ##;,#;:# #####'.: ####':;~ ~;##~'#:k //
<br />2
<br />90
<br />( 19)
<br />A!~a /+
<br />G
<br />).CSSOLYk:U MEASUREMENT b I
<br />IU1.9'_; 1 U t!
<br />I PER.M~T.:.: .:«c#.r,a,.#.::is: ':.::r~;-:xC,~:C: :: # ~:;:;#':;:::
<br />~ :;:rm*.xl:~;:: :r...PO.:~T::;
<br />:::`.:'H '. {THEY' ;R
<br />Afl
<br />
<br />:r'rLUF;rv'c hR.]ss vn[.o REQUIREM.~NT:
<br />F ~:::~:.:::.~. ..: ::.•~..: i:.: ::.. ~ ..
<br />'
<br />'.."`~ .. .:. . .
<br />NAME(FITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNOFR PENALTY OF LAW THAT I HAVE PERSONALLY F%AMINEO ANO
<br />AM FAMILIAR WITH THE INFORMATIDN SUBMITTED HEREIN; AHO BASED ON TELEPHONE DATE
<br /> MY INOUIflY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR ~
<br />~
<br /> OBTAlNINO THE INFOi1MAT10N, I BEDEVE THE SUBMITTED INFORMATION IS L
<br /> TRUE, ACCURATE AND COMPLETE. I AIA AWARE THAT THFRE ARE
<br /> SIGNIFICANT PENALTIEB FOR 9UBMITTINO FALSE INFORMATION
<br />INCLUDING
<br />
<br />T p,
<br />~J Narmon
<br />,
<br />THE P055181UTY OF RNE AND IMPRISONMFHT. SEE 18 U.B.L. E 1001 AHD ]~
<br />
<br />B NATURE OF PRINCIPAL EXECUTNE
<br />JD -
<br />~ O
<br />'
<br /> u.0.[. 1 Isle. (hwe.• i.qw m.a mrlma.n•r hcAd• r•wa Iq ro FIO,IXJd AREA
<br />TYPED OR PRINTED •n0or m.AMun YrlM.amrnr o/bnrwn smcnNa uM SVwrAI OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRelerence al/ attachments here!
<br />;tt'I"1'Lh:pII1,E :;CIL.Lhti L.It1.L1' 9PPLIF,S ONLY IF <= lU-YR, 24-lilt ?3FCIP EVP,NT 7S Ci,AT??~D. I? CLA.T'1 APPiLOYED 9Y
<br />ICU, 'L'S:; C!tUt7 LIf1I'1':; a.LLL NOT DE APPLIED TO REP09TCD ~NF,ASURP.MEHTS--SF,F 7. F.1 P, n(; II .14D T. U, 1D, PG 6.
<br />.,I„Tn,~gn•I•s.i .,E qt-:. ., v•1m n6TV B^'i }-1~)~
<br />EPA Form 3320-1 LOB-951 Previaue editions may be used. (REPLACES EPA FORM T-00 WHICH MAY NOT BE USED,( n ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ PAGE OF
<br />
|