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PERMITTEE NAME/ADDRESS p,.eL~e. fruiryNa.r//aanae I/OJt~e,9 <br />NAME , <br />-.. .. - .. .._ n~'i <br />ADDRESS ~~ ~ ~~ ^ ~ ~~ `~ <br />riAYi:c!r CO dlh3'd <br />FACILITY <br />LOCATION ' i ~' ;, _ \ 1, ..' _ ~ .: FRC <br />Forrn Approved. <br />r r .~ ,-~ r . I - -. -i ~~ :OMB No.,20~-0004 r""+,~-~~ <br />~~ ApDrovel explres~05-3 <br />Y~ ~C. <br />NOTE: Read Inetructiane before eompletinp [hie form. <br />PARAMETER 13 Grd Ontyl QUANTITY OR LOADING ~ '!~ pFd Ontyl QUANTITY OR CONCENTRATION NO, FREOVENCY SAMPLE <br />l32-371 !46531 !546!1 /3BJ51 !46531 !54611 EX <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />!sz-ss~ µALY515 <br />l54rcB1 TYPE <br />169-701 <br />v :, A::.~ lSi.. S.~ <br />i <br />~ L SAMPLE <br />MEASUREMENT <br />O ( oq) p,}>~;A' <br />~ ., .. ~ <br />/ <br />,. _ .~ 7 IS <br />r,i~J~~l~ 1 0 0 PERMIT ,... !; ::PORK 65=1 ^t, 4+bt(+ry 'aC t+:.... :: >:::'~~: <br />F'F. M.LY rr , <br />d. <br />Un, <br />c`t LJcb; .,=GSy Vn L'!I REQUIREMENT . <br /> <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?fTLE PRINCIPAL EXECUTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF LAW THAT I HAVE PERSONKLY E%AMINED MD <br />MILIM WITH THE INFORMATION SUBMITTED HEREIN <br />MD BASED ON TELEPHONE DATE <br /> ; <br />MY INQUIRY OF THOSE INDIVIDUKS IMMEDIATELY RESPONSIBLE FOq ~ <br />~ <br /> OBTNNINO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />TRUE <br />ACCURATE MD COMP <br />ETE <br />1 AM <br />WME TH <br />T THERE ME I <br />` <br />y <br /> . <br />L <br />. <br />A <br />A <br />SIOHIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING , <br />~-~.~ <br />~ <br />"I <br /> , <br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 18 U.S.C. ! 1001 MD G3 610NATURE OF INCIPAL EXECUENE G <br /> U.S.C. f 1310. lhlWess ~wY ens serlmrs nwY hchdr lows ~ ro J IO,OOD AREA <br />TYPED OR PRINTED rM rmssinwn i.wlsmwnr o/awsan smoeew aM 6YSrAl OFFICER OR UTHORIZED AGENT CODE NUMBER YEAR MO DAV <br />V V MM[N I D ANU CAPLANA I I V N Uf ANT V I V LA I I V NS InBEBIBnce B// BffeCDmB/I FS Re/B/ <br />.. ~ .~ ia.,. i-i~'..-.' .ifL .. :niYi:;i <br />i *. ~;. .. .,....I F.' Lii 'iOLI: ~ i,i':ii `; <br />_ <br />IlI I. is @ ~.} 11 '!. r~, ~e.:iLCAi:..~. :~:JLI'_ ~1'L- =FFI"= ~=F <br />~dA IV LJ ::~~'. ~iLY'i ~•JI:. .-...F ~`,c., ell <br />. J <br />'1 .; T°:1, TV 1 _ 1 r~l'•LF'4n~ I" <br />~l~~ ~~ ~. ~ <br />i CAL. `:::i' F.Vh:R?; ~f~.~, <br />.-. <br />^R~GF I~ 1.., <br />EPA Form 3320.1 108-951 Previous editions mey be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.) C n Il ~ ^ / ~ 7 ] ~: 3 1 -1 5;) PAGE OF <br />