|
PERMITTEE NAMEIADDRESS(lnrL4 imu+ry NwWlualan l/DIV~IrrIN)
<br />NAME l.YI'it,j~Ma'1h.L l.uYh'UrtA1IuN
<br />ADD~swF u uUx bit
<br />~ •:'~ (,KA1~ CU blbLo
<br />MATONAL POLLUTMT DISCNMOE FLIMINATON SYSTEM IIVPDES) Form Approved.
<br />DIBCH~R6EMONITORINGREPORTID rsl Wrlvt G ~N-.Y1n T'J QQJJ~~JJ9~°{{„;,0,¢0.000 . n
<br />4 Gp'pioveCe~{Ur~s 0 - 1-98
<br />~11IiK Nrt c? >
<br />PERMIT NUMBER DIBCNMOfNUMBDI t: - FIe~AL
<br />MO I TORtNSa PERIOD rl E !wl<
<br />FACIL GYFnU~ ~Mh'll:c i,L1kiJJKaTlUly
<br />MO OA
<br />Y ~ _ YEAR MO DAY
<br />LOCATION _
<br />I.KAIu l.L bI~LJ FROM •TO Jv ~Li :•vt~ NU J1SGhiArt(,t '. i"
<br />wT Ilv HI(,nAEL N. LUULUn, ukNEkAI F.sd f7aNl rzz 31 @4 ~~ !7677/!76-79113o-3f1 NOTE: Rudlnatraetlonsbe}geeompls npthNform.
<br />PARAMETER 13 6rd only! nUANTITY OR LOADING ~ _ ~•Clyd Onryl nUANTITY OR CONCENTRATION NO, R9E0uwcr SAMPLE
<br /> 1~6-53) 5461 13e~I61 ~ 1663 !61-61
<br />EX GF
<br />r519
<br />MA
<br />TYPE
<br />/37.371 AVERAGE MAXIMUM -
<br />UNI MINlAi1UM ' AVERAGE MAXIMUM UNITS rca•eal L
<br />(6b6e1 (66701
<br />I.IL Ah11 (, rtEASk SAMPLE ;. '.;F {, ;t{. ;i* ~ *1~# p{. {«i .},;. M4<. {. {. r.
<br />~ 1 jliAL MEASUREMENT ~,
<br />ovi,0o I O U ~:: PERMIT. ~:: QKVI#¢# ~.: ... .:..; ..
<br />.. ; .. .... • ..:
<br />L.hrLUt bROS1 VALUt ..:.:.........._.. 1T;1 T.'::::~ta~'~, ;::.r:.;;:,...:;:,.: .,..,.:::;::.;:..,..:~:;:;.: :. ;•<..... .:;:.;; o##k
<br /> SAMPLE
<br />
<br />MEASUREMENT /
<br />
<br />
<br />
<br />~ • .:
<br />
<br />£'rg...:::::.
<br />_<: ..
<br /> EOUjBEMENT~
<br />R ~... .....
<br />;'...
<br />,
<br /> .
<br />..
<br /> SAMPLE "~. ~,x. i~
<br /> MEASUREMENT ~ ~ ~ '
<br /> ...i~~PERMIT': ::
<br />
<br />
<br />
<br />.~ .~.. ...
<br />~ ~ .:: .:...
<br />
<br />
<br />
<br />..:.: :::
<br />,; .:..: :
<br />.:.:: ~..
<br />
<br />gj .': ..
<br />
<br />,:u,
<br />.....; .',,.. 9?i
<br />.... ,
<br /> ~REOUI
<br />REMENT ~ ~ ~ ~. .:~ .. ~. ~ . ;~ k F., -k: r'
<br />A
<br />t
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ~'~:.' PERMR..:~~ ~ ,~.~
<br /> I MELT
<br /> SAMPLE
<br /> MEASUAEMENT
<br />.. ..::.:PERMIT `.<:.;; ~.,. ~.: •: ~. ~..
<br /> REQUIREMENT. ~ .. :•":~:`:>~'..::..'::-::
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ~~.~PERMR... ...
<br />~. .:.
<br />.
<br />s::. ..;:. ..~.
<br /> :REQUIREMENT; ~ ~ ~ ~'~' '
<br /> SAMPLE
<br /> MEASUREMENT
<br />..
<br />
<br />.....
<br />:.~. PERMIT.: .' .:.~
<br />
<br />
<br />~ ~~
<br />REQUIREMEN7~ :.~. ~ ~~ ~'" ~
<br />.. ..
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cERTIFr UNDER PENUTr of uw TNAr KNAVE PERSONALlr ExAMI NED MD ~ TELEPHONE DATE
<br />AM FAMILIAR WITH 1NE INFORMATION SUBMITTED HEPDN; MD O ASEO ON
<br />MY INQUIRY OF THOSE INDINDUN.9 IMMEl11ATELY RESPONSIB LE FOR
<br />/• OBTNNING THE INFORMATIQN, I BELIEVE THE SUBMITTED INFORM
<br />Kichard ;\,IIIS ATION IB
<br />/
<br />TRUE, ACCURATE MD COMPLETE. 1 AM AWME TNAT TNE
<br />l Milis SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION, IN
<br />E
<br />i
<br />t RE ME
<br />q
<br />CLUDING (97 J3]O-2]t2
<br />] ~] 93
<br />nv
<br />ronmen
<br />a
<br />THE POSSIBILITY OF RNE MD IMP11150NMENT. SEE to U.S.C. ! 1001 MD 7J
<br />E
<br /> ooo
<br />rArs.rd.. uw ewr mnm, .I.r FroA,ei es., w ro s rD
<br />1 tars
<br />u
<br />s
<br />c eIONATURE OF PRINGPAL EXECUTN AR A
<br /> ,
<br />.
<br />.
<br />.
<br />.
<br />OFFICER OR AUTHORQED AOENi NUMBER YEAR MO DAV
<br />TYPED OR PRINTED .nlnnavFwn Mprlonr+ta/bnr«n enwnlu rN$yrra/ ~ CODE
<br />COMMENTS AND EXPLANATION OF ANV VIOLATIONS lRe/erence s6 strocnmants Hare/
<br />,ctTLriA•uL.r_ Si.L1uS L1'+lT r,A1vCL, run iUYK,L4NK. F'.<tC[1' EYttvT-Sct I.A., p., 1V, FUR nt4iJllteFlEhi~. uIL
<br />ul<LA$t v<.iU SAM?Lc AN„LY~1S r~t..U1ntC Ii- ViS1dLt SncLi+ IS L~btKV;.u. .ir ir<LY SAi1PLINi, I>IST;<UtTILru-I.(,.a,
<br />~r
<br />EPA Form 3320-1 LOB-961 Previous editions mey be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.) PAGE OF .,
<br />VQ17G/9C.lOJ1.-1~1~ ~ y_ ,.~__. 1 _
<br />
|