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PERMITTEE NAME/ADDRESS pndiO Fr~WryNaw/Lzsnm gDl~isN1 <br />NAME :gip 4,'i;n ,"),','-.L C~~~fIE r. ~Y <br />ADDRESS ~ F A . i; :5 L <br />i1A'fet6 <br />CC 81bJ/ <br />FACILITY <br />LocAnoN h A f J c h „' ` ,~ ~, 3 ~ <br />A '[" l R : V . ~ 1, i' c t l ~ ~ l; i l , G L ~ : I A L :': ii ~. A , ~ : .. <br />NATIONAL POLLUTMT DISCNMOE ELIMINATON SYSTEM INPOES/ <br />DISCHARGE MONITORING REPORT IOMRI <br />/2-I61 117-I91 <br />C;~0.1C^vi.'1 CCh <br />PERMIT NUMBER INSCHARGE NlM+IBEA <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM w ~i- TQ. +r ^ <br />!167/1 I¢]-131 /11-I51 176-771 IIB-191 /363/1 <br />Form Approved. - ~ <br />• ~ ~ .: [ ' ' I .CjMBrNo.1204C~000¢ <br />,~ Approval expires OS-31 8 <br />- Filial. •$ <br />NInCa i <br />NOTE: Rssd Instructions 6sfors complstinp thin form. <br />PARAMETER !3 Card Onlvl QUANTITY OR LOADING !~ Grd onhl QUANTITY OR CONCENTRATION NQ FREDUENCY SAMPLE <br /> <br />131-371 /46-531 154-61/ l3B-I51 /46-53) 15F6/1 GF <br /> EX MALYSIS TYPE <br /> AVERAGE MAXIMUM ITS MINIMUM AVERAGE MAXIMUM UNITS l67~6J1 16q-661 169-701 <br />GI_ AXU G;: [.Aih <br /> <br /> <br />YI SAMPLE <br />MEASUREMENT <br /> <br />.... -.- <br />.. <br />~ <br />t `I Qf,:. <br />~~`'~ <br /> <br />. <br />.-'. Y.rry. <br />'.{;::::;-'.: <br />O <br />'/ <br />U <br />~ <br />_~ AL 1 <br />~~+i v[!D 1 ;1 G PERMIT ~ ':: "+r67'f 1k RE~'OFT .=i Ca i#bII.ri 0•yKOt,°: ~ i-:h ~:;.;?-;I irr,;: ;s <br />r'.EKLY T+"t <br />/_,.LpI <br />.;Ft'LU6;~: ;.;'I'"P ;A%.n REQUIREMENT ,, ,,, ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTFY UNDFA PENALTY OF UW TNAT I HAVE PERSONALLY E%AMINED MD <br />AM FAMILIM WITH THE INFORMATION SUBMITTED NEREIN <br />MD BA <br />EO ~~ <br />~ TELEPHONE DATE <br />L~ J p ~ M ` j ~ O ~ p <br />u S ; <br />S <br />ON <br />MY INQUIRY OF TNOSE INDINDUALS IMMEDIATELY RESPON4BLE FOR <br />OBTNNINO THE INFORMATOH <br />I BELIEVE THE SUBMITTED INFORMAT ~ <br /> , <br />ION IS <br />_ <br />I1 TRUE. ACCUMTE MD COM0.EfE. I M1 AWME TNAT THERE ME <br />SIGNINCMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING _ <br />I // <br />~ <br />( <br />.. <br />~ (/ V <br />~ ~1 , <br />THE POSSIBILITY OF FNF MD IMPRI <br />ONM <br />EE I <br />T <br />S PA O ~ <br />~ <br /> <br />1 <br />S <br />EN <br />. S <br />B U. <br />.C. f 1001 MD 77 <br />eIONATURE OF INCI <br />I EXECUTNE L <br />/ <br /> U.S.C. 1 1 a t s. IMWOiA IA+ar e1.r mnm. n+rr ileAdA 6wA w ro S IO,000 AREA <br />TYPEWOR PRINTED AM nmuimAn l++PdonwNOlbIwAN+e mardrArp6rwral OFFICER OR HOR12E0 AGENT CDOE NUMBER YEAR MO DAV <br />GOMMtN IS AND tXYLANATION OF ANY VIOLATIONS /Referents s//attschmenb here/ ' <br />-.,, Li".1! [i,L 'a6I'1 .LI F. :,. ~Ei: '!L.': !. .i G :i':L1:._ LI "':~ A?PL. "~!' FCs <_:!' <br />'L YF,:L PFFCI?' °"J=:r .: Tom`- !~ <br />..ti:L,tA:.~ ."[.:~-, LI"I', 'nA1JZil FU}' >1JYF:,21iri 1'-iF;C':C '7: ':; SLfJcC' ?C FC:.-c+, C° ~~OUr Y'. I.d.~. .~I' .. <br />+.n ~.A ~r-'; T_I,.1_n. ^:,; +!rlNr rncrN:_~s•r -, <br />EPA Form 3320r1 108-95) Pravlous edlGona may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 Q Q r ~ ~ ~ ~ 7 1 0 l I- I ~+1 3 PAGE : OF <br />