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PERMITTEE NAME/ADDRESS pI~rL F«WryNsWL«anar UDlSi.mp <br />NAME TERKOR ::rL'd; ~~"~1;iY <br />ADDRESSTESROR CRF.dK LOAD~UT <br />18UU RIGR4AY 133 ' <br />PAOtI1R ~0 B1Ua9 <br />FACILITY ' <br />LOCATION ~ I <br />ATTN: KELLY PRITZLER, OPERRTIORS 'IJR <br />Form Approved <br />J ii'..:1 IJ f t' J 1i D :T J^i ON~~1110. 20u4Q~004~ N <br />(S l' d R a C) APProvel ex~l~~ 631.58 <br />F - fI'lAL LL <br />1I*'OR <br />t~'=+ v0 UISCHRRGE ~yY~ a-a <br />NOTE: Reed instructions belore completing thu lorm. <br />PARAMETER l3 Grd Only QUANTfTY OR LOADINQ; !1 Gr Only! 4UANTITY OR CONCENTRATION <br />"' :RIO. FREQUENCY SAMPLE <br /> !4653/ 150.61/ 138151 !1653/ /546/ <br />~ OF <br />131-37/ EX ANALy515 TYPE <br /> AVERAGE MAXIMUM UNIf6 MINIMUM AVERAGE MAXIMUM UNITS re7.631 I545B1 158-701 <br />., EASE SAMPLE ca sass ~ ( 9'1) zaagl* asa as 4'::~;:<:"-': <br />I J U A L MEASUREMENT - , <br />Y066 ~ U D PERMIT. 30a0a0 <br />R:C)7~EIt{! Y <br /> <br />C- <br />e.,-1 <br />:,.aaals~a:a~:., <br /><-:•.:aF~,xr T <br />YYYM~~... <br />~-~: <br />fY.Rtt <br />IlsuAC. <br />PPLOENT GROSS YAL7E REQUIREMENT, r~_ r.~zr.:.. <br /> SAMPLE <br /> MEASUREMENT ' ~. , <br /> .:PERMIT ~ ~ ~ ~ ~ <br />... ~~ <br /> <br />-,: ~~ <br /> .REQUI.RE.MENT ~ ~ ~ ~~~ ~ ~ ~ ~ <br />,t :.q <br />~ ~""~ <br /> SAMPLE <br /> MEASUREMENT " <br />. <br /> .: .PERMIT ~ . - ..... : ... <br />:,.. :., ::.. <br />,:.: <br /> REQUIREMENT: ~ _ .. .. :~? ~ :-:~. <br /> SAMPLE <br /> MEASUREMENT <br />~ <br /> PERMIT .. .. ~~ ~ , <br /> ;REQUIREMENT ~ ~ ~ .. <br /> SAMPLE <br /> MEASUREMENT <br />x <br /> ~~ ~ PERMIT ~. ~~ - ~ ,.. . ~ .... .~..:. .:: ~:`.' <br />~ <br />~ <br />~ <br />~ <br />~ ~ <br />~ ~~ <br />~ . ~ .. ~ ~ ~ .,;_: y:;:-; . <br /> REQUIREMENT ~~~ ~ ~~~~ ~ ~~ <br />~- <br />~ <br />~ <br />~ <br />~ ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ ~ ~~~~'~~ ~~ <br />~,>. <br />z.:r:. <br /> <br />REQUIREMENT <br />~ . <br />~ . <br />~ '~~'; x.<~:~ <br />er.:. <br />. <br /> <br /> <br />. <br />~ ~ <br /> <br /> <br /> <br />~ <br /> <br /> <br /> <br />~ ~~ <br /> SAMPLE r <br /> MEASUREMENT ~ <br />" <br /> ~:~.. PERMIT .. ..., <br />,, .. .., :-. <br /> :REQUIREMENT . ~.. ... ~ . ~ ~ .. ..:..:.:•.°.... :. .. <br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I cERn <br />AM FA Fr urrDER PENALTY OF L <br />MILIAR <br />WITH THE INFO Aw THAT I NAVE PERSONALLr ExAMINFD AND <br />RMATION SUBMITTED HERDN <br />AND BASED ON TELEPHONE DATE <br /> - <br />MY INQUIRY OF THOSE IN ; <br />OINDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTNNING THE INFORMATION , I BELIEVE THE SUBMITTED INFORMATION IS <br /> TRVE. ACCURATE AND COM <br />SIGNIFICANT PENN <br />TIES FOR PLETE. 1 AM AWARE THAT THERE ARE <br />SUBMITTIXO FALSE INFORMATION <br />INCLUDING J( .ice __ <br />r r- I -t /rl L IA ~D <br />t L LY R <br />T <br />L E R <br />P R <br />AT I ON 5 . <br />P , - 07n ~~ <br />~ <br />r <br />1 ~ <br />, <br />~ <br />, <br />. THE <br />OSSIBILITY OF RNE AND I MPWSONMFNT. SEE 18 LLS.C. ! 1001 µD 3G <br />INC AL EXECUTIVE <br />-~ 810 E S 5! 5 ~ ~ ? <br /> us.C. E t ate. lnNrel.• uW.r Ie.« NroroF roFr icAUd, ~uwa rAP ro r/o,DOO, 4 AREA <br />TYPED OR PRINTED w«mu:.l«n lrwr/laanwnr we.wF.nemetdo rN6yrrA1 OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV <br />1..VMMCNIJ AINU LARANAIIVN Vt'AIYT VIVLAIIVNJ r/rlle/enCe a//eRICOTYOfS /ie/e/ -- , ~1 <br />SETTLEA9LE SJLIDS LL.'1If Ar'PLIc3 OMLY IF := LO-°R, 1U-H3 PRE;TP 1iYSbI TS CLnIt'EG. IF CLRLM APPAOYF,O 9Y ' <br />YQCDe TSS 5 CRJ~Y LC9IYi WILL 9DP i3t APPLL::D TJ REPCRTE7 7EA:;U81F!lSMTS--S ° I.P„lA, PG 5 AYO I.1?.1D, PG b.~ <br />STONNYATV.H Nau~,:EMPNT LIaN a11F t-T-vy. <br />EPA Fam 3320.1 (08.951 Pretrioue editions mey bs used. (REPLACES EPA FORM T-00 WHICH MAY NOT BE USED.) O1 b 8 / 9 7 D 819- 125 4 PAGE Z OF <br />