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~~ ~. <br />PERMITTEE NAME/gDDRE55 (f, Yb FacWryNwV(,ecanm /Ot~ir.nr) NATIONAL POLLUTMIT DISCHMOE ELIMINATION SYSTEIA INPOf$/ Form Approved. <br />NAME ~' ~ ~' - ~ ~ ~ ~ - DI9CEIARGE MONITORING REPORT lOMRI <br />@-181 l17-191 ~ ~~ ~~ - ^ OMB No. 2040-0004 ~ •• <br />ADDRESS - ' •- i e ~ ~ - ~ ~ :.. ~ •. -' n - - ~ ` c l ~ ~ , ~ - ~ I Approvt4 expires OS-31-98 <br />~ -- - ~ . , PERMIT NUMBER OISCNMOE NUMBER - _ <br />FACILITY ~ ~ MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />_ FROM I I, ~ TO .. ~ - .. I -__ I : <br />I ~ ~ NOTE: Raed Irotruetiorr belae com I p <br />' - ~ ~ ' r !76211 177-731 !14751 176-771 118-291 130.3/1 P elfin this form. <br />PARAMETER I3 Grd OnIY! QUANTITY OR LOADING !1 Grd OnIYI QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE <br />l37 <br />J71 (16-531 15/-61 I3B-45 !46-53 I5b611 DF <br />- EX N <br />uY~S TYPE <br /> <br />- AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS Ie7-ssl 'a <br />' <br />164681 169-701 <br />;. SAMPLE <br />MEASUREMENT ' '. ~: ~: •::_ .. .: .:: :... <br />', ~' ....:, .. <br />~% ~ S 1 .Y <br />~1 ,~ <br />/' ~ ~ <br />(yl ~~ <br />.: (.' PERMIT "t q • -. ^• Y• ~ ~ r •; r. i .:t . . o <br />,. 1' _ - ' . ~ ,r - ~ I . REQUIREMENT - <br />~ <br />ti T / .' F . • ' ` i ~ •- •. ' SAMPLE ... [:.. ..: _ ;..., _ <br /> <br />MEASUREMENT <br />N ~ <br />~I {~ I , <br />nl /` <br />N {i <br />n~ /~ <br />• .'r i' '' PERMIT 'Y:~h:g rr •'. °t r:a-.het $. n+.. .. ... .,. e(r= r^pr. nr n• I•^ . <br />' <br />V I,. T ~ <br />. . <br />C :, ~ •. a" '1 s REQUIREMENT is ..}f. 'Tn •,y y. ..F-r.r :~• /I, "(1t: Tft <br />. ~.._ . • ~ , . ~ ~'•. L t ' I ` SAMPLE ': •r r:.. ,..: r: •;: .. ...r..,:.:. ; , ~ <br />I I <br />'/ / <br /> MEASUREMENT C 0. ~ ~ ~ , I j (J ClF <br />A <br />. `...1 .C ii PERMIT ''a ~: ': r G .. : r.. .y . ... : t _ <br />^t ..:-f ,oa <br />,1.•r. '.R GR~i" REQUIREMENT ~n-. c tv `- , <br />~ <br />_.- .. '. i. :FF.AS'' SAMPLE _~~. ~ ~ <br />~ ~ 'r;: <br />~ ~ ~ ... <br />I ~ <br />_, - v i',~,_ ;~ `-. ~-.~ MEASUREMENT /11/~ NA IV <br />/q N/.~ <br />t' . ~, ^ 1 17 ^ PERMIT ~ r' :' ° : ~ G .~ G .: r... r.. . -.,.. . , ~ : <br />' 1 ; <br />I <br />U , ., REQUIREMENT <br />. ~ <br />'L~ ~~ I `~ ~L'~(i'rT SAMPLE ~ 1 °~ ... ... .I .. ~- <br />~~' T T <br />J I <br />~ MEASUREMENT ~ 0 z S f Q <br />(~ <br />0 g( <br />. <br />~ - <br />/ <br />1 v . _ •`7 G ~ PERMIT ~ ~ ': '" :i c ~ ..~-;, ~ <br />.G: ~n <br />~ ..~ • ~ <br />.... .. <br />.. <br />_ ~ ,. ;I 1' .~ •.. <br />~ REQUIREMENT t~•, ;1 kY~.; is ~.I L <br />" '1 <br />~ t sr( .• <br /> <br />• <br />, s,, ~• I,-...-' <br />,_ <br />' <br />' SAMPLE :~~. .,.; [: :: <br /> <br />~ ` , <br />y ..,.. ,,:.:. <br /> <br />~/ <br />", <br />, • <br />[, MEASUREMENT 3 ~ 1~IJJA <br />•1 ~~t„ ' I' PERMIT .::r:^r• 7 _~ ~..._ .:I: .~~~. ., t. ,y. ,. <br />- -. ~~ . ~ ' . .: ~. 'REQUIREMENT 7 }~ ' 'I '~ " ~ .. <br /> SAMPLE <br /> MEASUREMENT <br /> 'PERMIT. <br /> REQUIREMENT <br />NgME/TITLE PRINCIPAL EXECUTNE OFFlCER I eERnFr unDI:R PENN.rY DF uw THAT I NAVE PERSO NALLY ExAMweD AND TELEPHONE DATE <br /> AM FAMILIM WITH THE INFORMATION SUBMITTED H EREIN; AND BASED ON <br />1y <br />C Viz Y'CI 1' Ills MY INQUIRY OF THOSE INDINDUAlS IMMEDIATELY RESPONSIBLE FOR <br />OBTNNINO THE INFORMAT <br />I eELEV <br />ON <br />T <br />~ryt I <br />, <br />E <br />HE SUBMITTED INFORMATION IS <br />U <br />r <br />_j.VlYai?1i8`7:'~ i ,`:C~';~_Y SIGNIFICANT P <br />ENKT~S FOR SUBMITTING FALSE MFORMAT <br />ION?NCLUD NG <br />' 77~ (i~]n-?7.r19j '17 <br />7G t•^ <br />J <br /> <br />THE POSSIBILITY OF RNE AND IMPNSONMENT. SEE to U.S.C. 1 1001 AND 3] u <br /> <br /> <br />TYPED OR PRINTED <br />u.s.c. I t]te. rA.nru., uldor dws mtm.,.,r.r NcAdo 6.Na Im ro sro,aoD <br />uM Ormul+,vni.wivnweo/Ntrorr enlmMrt ondS FOrs/ BIONATURE OF PRINCIPAL EXECUTIVE <br /> <br />OFFlCER OR AUTHORIZED AGENT <br /> <br />NUMBER <br /> <br />YEAR <br /> <br />MO <br /> CODE DAV <br />.,vmmo. ~., .......,...n ............. ..~.. .~...... ~..~... L... e. enter rn susarnsns nrrr/ -_ <br />• ~• '. <br />. T r.. ~F- / r • .. <br />EPA Form 3320 T 109 951 Prevloue adlDane mey be used. /REPLACES EPA FORM T<O WHICH MAY NOT BE USED.1 .. , I ~ I ~ „ , , , _ ~ , PAGE I OF <br />