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• i6~ <Yw Cd 3a 4 <br />pERMf7lE~ NAfAEIA~H(ik`b45(fnrYdr Ael~iry Na/WrmmlJDl))'irww) <br />NAME <br />ADDRESS .: 1 , ; -. ~ ~ ~ ~ , <br />6' 1.1, ~i <br />FACILITY ~ _ , <br />LOCATION <br />i r <br />NATIONDISCLHARGEDMON TORING REPORT lOMRIP ~~ <br />1-161 17-191 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM , I ,, ' ? TO , ~.1 -, i <br />170-711 l12-231 !74761 !I&771 l2B-291 130-3r1 <br />FOrtn P ppl . , ~~ <br />„ I 1 , .._ QIy,Itfj_ No. ZlOair-uv:r. <br />- _ ~ ~ Approve~~ex{~ir~s,05-31-98 <br />(: I ,. J _ 1 <br />~ _ c ; ~ .. <br />.. .. .. .. I `I .. ..: <br />NOTE: Reed Inetrucflorle before completlnp thM forriiy <br />PARAMETER !3 Grd Onhl QUANTITY OR LOADING !4 Grd OnNI QUANTITY OR CONCENTRATION NO FREOUENOY SA <br />' <br /> !46-53 (64611 !38-16 !4663 15461 EX OF TYPL''E <br />!32371 ANALYSIS <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS re=-eel lyF68J l63-701 <br />- , ~, . ~, .. <br />"" SAMPLE ~ ;~ .. ~ .. . . <br /> MEASUREMENT <br />~ <br />~- <br />L <br />J <br />' <br />PERMIT <br /> <br />.. .. <br />':Fy p <br />,: ~Y;" .. <br />7' I°k':: <br />,. .. <br />.. <br />.. `! <br />~ i; J <br />„ ~ . <br />. REQUIREMENT ` <br />,....' <br />; i <br />, <br />. . ~ <br />. <br />~.t -_ - <br /> SAMPLE ` <br />~ <br /> MEASUREMENT 1i / ~ , ~~ ~ <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 /> flEQUIRFMENT <br />NAME/TITLE PRINCIPAL E%ECUTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF UW THAT 1 HAVE PERSONALLY E%AMIMED AND <br />MILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED Ok F TELEPHONE DATE <br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR : <br />I _ <br />11, ~ ~ 1 (' Yj--A <br />' <br />1 <br />` OBTAIMINO THE INFORMATON, I BELIEVE THE SUBMITTED INFORMATION IS / <br />, ~ - <br />, <br />L <br />II TRUE. ACCUNATE AND COMRETF. I AM AWARE THAT THERE ARE ?~' <br />~ r <br /> INOLUONIG <br />T PENALTES FOR SUBMITTING FKSE INFORMATION <br />S <br />NIFICA , <br />1 <br />I I . ~ - ~ I~ ~ t, 1 , <br />IG <br />N <br />THE P0591MLITY OF RNE AND IMPRISONMENT. SEE 13 U.S.C. 1 1001 AND 33 i <br />SIDNATURE OF PRINCIPAL EXECU7NE <br />/~ ~/ _ _ <br />~/ ~ <br />~ 1 <br />/ <br /> U.S.C. F 1 ]10, fhnYtlrr udr 01rr mums ,rrY 1xrAAr a*v w ro f 10,6'00 AREA <br />TYPED OR PRMTED .nd armuirP.n iµvironrnntW errwwn e,nwerW6Yrra1 OFFICEP OR AUTHORO'EO AGENT CODE NUMBER YEAR MO DAV <br />COMMENTS AND EXPLANATION OF ANr vwLa I IONS lne~xenes en srtecnmena oars! <br />_ r <br />EPA Fo'rr1C 3320-1 08= 1 Prsvloua sdidons mey'be used. ~ ' - (REP CES EPA FORM T-40 WH CH MAY NOT BE USED.) ! PAGE OF <br />, - <br />