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PERMITTEE NAME/ADDRESS 0~4 fxWry NatlLp.ulm /D.pinm) <br />NAME r"I ,. .. - - <br />.ors <br />ADDRESS ~ = ~ - 1 ~ , <br />- a , <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTMT DISCHMOE EUMIMATION SYSTEM lNPDESJ Form Approved. <br />DISCHARGE MONITORING REPORT IOMRI OMB•,No:~ 2040-0004 <br />11-161 I17-191 '~ I r' <br />^' n - ~ ] ~ ~ ~~ ~ ~. APProvel exPirec OS-31-98 <br />PERMIT NUMBER DISLNMGE NUMBER _ -• • r . ~~ <br />MONITORING PERIOD <br />YEAR MO DAV YEAR MO DAY <br />FROM ~ TO _ ._ - .. .. I T- I <br />110-atl raaa3l rah-asl las.an !sa-asl 130-31J NOTE: Read Inetrucflam 6afwa completing this form. <br />PARgMETER !3 Grd Onlyl QUANTITY OR LOADING !1 Grd OnlYl QUANTITY OR CONCENTRATION NO. FREGUENCV SAMPLE <br />I3 106-531 154-611 138-451 !46531 151-5/ OF <br />Z-37I E% ~ <br />LLr~S TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS lea-s]1 ' <br />' <br /> 164651 /6¢701 <br />„ . • ~ - ~ ? SAMPLE r< (: ~ r• ~. ': r -. .. ~ ! - 1 <br />(;, .. .1 MEASUREMENT <br />• .1 _ PERMIT ~ :. ~: .. •,.: ... o. ?; _y ~ c >r <br />•1'-.. J <br />a q <br />j, .. r 'REQUIREMENT rv~ r- ~ <br />:.~ ~ I 1' . ~. Il j " t' SAMPLE ( ~ 71 •: ,....... .... <br />„ , , , : r I; r ,~ (, ; r~- MEASUREMENT <br />.I)~.''I 7 r: 'f .PERMIT t-.( ~1 ::r ~°".T 7`.A ~. Xr,•r; y, w.. ... ',;rc ••r 'I fr;^.rt ! <br />~1^•~ A <br />- „\_. h• +~ <br />J REQUIREMENT ~, _r^ SC:. •,LI „Y MY r-~ .. '. <br />A'-^ ~.~.. ..: _, <br />]: . SAMPLE :;: ;.c ;: ( ~q) :..; ..... ,. ... ...:... .. ... <br />![- :{! MEASUREMENT <br />":I. , _ 6 :~ PERMIT Itt_f:rvp: t;. Y <br />~ '-~] yy. ~;,.•.,.:. ... 1: .. •:{.v:; i• ~ ~pt,y rT't•~• <br />- -: `i ',' li F :1 .i - REQUIREMENT r e; r p .; J, :{ "'~= i' <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 cERn <br />AN1 FN FY uNDEn PENN.Tr DF uw THAT I NAVE PERSONALLY ExAMINED MD <br />NILIM WITH THE INFORMATION SUBMITTED <br />EREIN <br />MD B <br />SED ON TELEPHONE DATE <br />I2ICh~rci I•IIIi; ; <br />H <br />A <br />MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />_ <br />L:!1VITGf'!;`IP:T ^.r.i ~ <br />lillilq~ C TRUE. ALCUMTE MD COMPLETE. I AM AWME THAT THERE ME - ' <br />. SIONIFCNIT PENN.TIES FOR SUBMITTING FN,SE INFORMATION <br />INCLUDING U <br />1 L <br />( <br />? <br />r <br /> , <br />THE POSSIBILITY OF RNE MD IMPRISONMENT <br />SEE 1 <br />1 1001 7( <br />- J <br />}- <br />7 <br />j~ 1Z ZII ~I~ <br /> . <br />e U.S.C. <br />MD ]~ SIGNATURE <br />P <br /> <br />TYPED OR PRINTED U.S.C. ! 1 ]1 B. IMulellr ue6A• rMS mNrol ^rY hepm rMMF W ro S IO,OW <br />qu <br />i <br />N OF <br />RINCIPAL E%ECIRIVE <br /> r <br />mu <br />mn.M+ <br />emrre o/Mf\Iwnemeneu end6 ylerAl OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV <br />L,vmmcn • v nn~ cnr coon • rvn yr n•.. vlvcn ~ •vw Inerwnnce an srrscnmenrs oars/ <br /> <br />i J C ~. •1. . , • ~ T I ~ ' F 1 <br />. ~ T _ • - ~ _ I I ' - ^ . <br />. '\ i -,. I ~ r .~ ., ... - <br /> . <br />I <br />' I <br />EPA Fwm 3320-1 108-65) Previous editions may be used. /REPLACES EPA FORM T40 WHICH MAY NOT BE USED <br />1 <br />PgGE <br /> . <br />„ J „ 0 i ,. ~ _ ~ <br />OF <br />