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PERMITTEE NAME/ADDRESS P.rbi F~WryN~/Foculm IJD~q <br />NAME GRAdil YASLi:Y C ~qL t:'I^~ :. . <br />ADDRESS NON;,ER CANTON '1iNr. <br />P.O. UOY 70 <br />LOMA Co 41924-0070 <br />FACILrrr GRAND YALLt:Y COIL CORP.~Mi <br />LOCATION <br />A TTS: JOHN fl. YALTf:RS_ 1~i Mlcwa <br />Forrn Approved. <br />+.C!:^F: 'JET TFSTIVG~~~~rj~i053t-s8 <br />(SUB& MC) 12345 <br />F - PINAL <br />NINflB ((gi'p{~ <br />'~H ~ ~I.St1TlC)1~_~ Mtinp this fwm. <br />PARAMH'iER l9 Ord Oglyi QUANTITY OR L ~ OnfTl 4UANTITY OR CONC ~ ,N0. mEGUENCr SAMPLE <br />13I+?7/ !~ 3/ /5467 I3B.15 14653 5F6/ EX OF <br />MAirsls TYPE <br /> AVERAGE MAXIMUM MINIMA AVERAGE MAXIMUM UNITS 63-fa! !6468! (69-70! <br />LCSU SP.ATRE 49%p AC tRORCTi G~Ct;rX ~f4fk#r , ,.rt~II i 23) <br />C::!tIODAPNRTA MEASUREMENT <br /> '~ <br />PERMIT . ~ <br />~ .:::.: :. :.....Y ... <br /> <br />~$OF~ ~ <br />~ <br /> <br />Svc <br />/E .. <br />~~`~` <br />~ <br />~; <br />OO <br />~ <br />:~ <br />.. <br />~.:~. ~ACfsik ~c;t ~ <br />:. <br /> <br />:' O$~}'Q~.:;;s, <br /> <br />R- <br />..: <br />~~~:'~:'~: .. <br /> <br />''~yELL <br /> <br />RAA <br />. REQUI(iEA!IENT ~. <br />.~:::. <br />a . <br />.. .. ~, . <br />. <br />..: <br />. <br />: <br />. <br />I <br />~ . . <br />. <br />x• <br /> <br />. <br />:" <br />. <br />. <br />... <br />LCStf SYATRS 9hHi? j('i SAMPLE ::::3 .?4 ~ ' <br />1PRC4C~ •^.t#.'k#.'I ark ~'.`-}k# ( 2j) <br />P I M F: P H A L ~' S MEASUREMENT <br />TAilh(: 1 0 U PERMIT k:t;`Cfi;t ..:;~~'~i!*: <br />: .00~~: ~ a7#4Lr~;t .~ a~#va~~ ~ ER- .,~. ~t`.6L~i ,AAB <br /> REQUIREMENT , <br />, <br />.. ~~ <br /> SAMPLE , <br /> MEASUREMENT <br /> PERMIT -~< <br />~~~ <br />~~ ~~~ <br /> ~REOUIREMENT ~ <br />~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ <br />~ <br /> .~tEOUIREMENT ~ ~ <br />~ ~~'" <br />~:~:> ~.~ <br /> SAMPLE <br /> MEASUREMENT <br />- <br /> .. <br />PERMIT :,:~: •. ~: ~ <br /> . <br />REQUIREMENT: L"' .:, :,. ' .. <br /> SAMPLE <br /> MEASUREMENT <br /> .. PERMIT. ~ : ~:. ~ ,,... , <br /> ,, . <br /> SAMPLE <br /> MEASUREMENT <br /> .PERMIT <br /> :RE(iIiIREMENi <br /> ~~ <br />NAME/i1TLE PRINCIPAL EXECUTNE OFFICER I OERTIFY UNDER PENALTY 0 <br />AM F <br />MILIM <br />TH T A Y THA71 HAVE PEIISO <br />TTED N <br />TION SUBM NALLY E%AMIN <br />MD OA <br />EREIN ED MD <br />SED ON TELEPHONE DATE <br /> A <br />WI <br />HE IN <br />N1Y INOWM OF iMOBE I <br />OBTNNING THE INfORMAiI ; <br />A <br />I <br />DVALB IMMEDIATELY REBPONSe <br />1 flEUEVE THE SUBMITTED INFORMA LE FOR <br />TION 19 / 1 <br /> <br />TRUE, ACCUMtE AND COM <br />SI <br />IF <br />AN7 <br />E <br />A <br />T <br />F <br />R S <br />PLETE. 1 AM AWME THAT THE <br />LSE INfORMAT10N <br />INC <br />TTIN <br />UB <br />F <br />RE ME <br />LUOIMG ~ "~ <br /> <br />/1 <br />I ~' I (~ ~~_ GN <br />IG <br />P <br />N <br />L <br />IEB <br />O <br />THE POSSIEILITY OF FINE AND I , <br />MI <br />G <br />A <br />MPIIIBONMENT. SEE 10 U.S.C. 1 1001 AND 3G lIONATyRE OF PRINCNAL EXECUTNE N T ~ / <br />/ ll <br />TYPED OR PRINTED . a w.na.ai+wn (~o/aMw^ s napnn~,Yls ~jvra~i ~° ~ f (O~~ OFFlCER OR AUTNORI2ED AOEM A <br />CODE NUMBER YEAR MO DAV <br /> <br />COMMENTS AND CAYLANA I I V N V F ANT V I V LA I T V n15 lnei~l/nc~ el/ RroOnmYnrs nl/a/ <br />5 I. A. t, PP 4-/, PDi UF,*AILS OF TF.57 Pk~C60UR~. RPPORT LCSD - STATISTICAL POINT ESTIRATF. NHICH 7S <br />AL To SOX OF TEST JHGANIS!1S, ANO ATTACA ACOTE TOLICITL TEST ASPORT PORN TO OMK. COPIES OP ALL <br />c VOCY.1 YAVC <br />00312/96121?-1206 1 <br />