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eb'c.t~ tR 1 <br />pERMIT~E IJAifF'JAb~Fti€S$pal.d.!?sWryNaWL«u4v, dDIJJ nwr1 <br />NAME , <br />ADDRESS r' • ..` ~ .. n ' .., ; - I, <br />r 4 I ~- ~,~ <br />FACILffY' r <br />LocnnoN ` ` ~ ~ ` <br />i <br />NATION ~SCLFULRGE DMON TORING REPORT (OMRIP~~-~ <br />/I-161 17-19 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM } t I ~~ 1 TO ^~ 1 ~ ~ : i <br />116111 l12-131 !~I-151 126-?7l f28-191 !36311 <br />Form P,ppl . r ,.. <br />,~ ~ T 1 ~ , iObBryo~20nu:ri.:.. <br />i ~ ~ ._; ~ - Approval expires OS-31-98 <br />l~:: l <br />~t ~ !. <br />, .. f <br />I <br />NOTE: Rssd Instructloru bslore eomplstinq this form. <br />r <br />PARAMETER !3 Ord Onlyl QUANTITY OR LOADING !4 0.rd Onlrl QUANTITY OR CONCENTRATION ND IREOUENCY SAMPLE <br /> !4653 154-511 !3B-<51 !4653 15~-511 <br />EX DF <br />TYPE <br />!31.371 ANALY915 <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS mt~sn 154581 !59.701 <br /> <br />~ SAMPLE ( ~ <br />~ .. .. - . <br />~- ~' I` ~ ~~ ~~ <br />~ MEASUREMENT <br />i <br />,., .. <br />. <br />(; <br />PERMIT ~ <br />:.:.:.;~;,r.; <br />... <br />.. Z! <br />; <br />, k 1 7 3 <br />i. ~:_! <br />... rn`:;: <br />:Y is r.^: i:~ <br />... .... <br />-.~.1:LY~ <br />°~Y~r~B.A: <br />• ' , .., ,. REQUIREMENT . <br />. <br />~ . <br /> r: <br />rGT ni. I <br /> SAMPLE <br /> MEASUREMENT - ~ ~i ') ~ f <br /> ~~PERMIT ~ <br />~ ~ ~ ~ . <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 />I <br />NAMETTTTLE PRINCIPAL EXECUTIVE OFFICER I CERTI <br />/ <br />M FA FY UNDFfl PENALTY Of LAW THAT 1 HAVE PEA80NALLY E%AMINED NID <br />MILIAR WITH THE INFORMATION BUBMITTED HEREIN; Ni0 BASED ON <br />- TELEPHONE DATE <br />1 11 <br />^ I <br />~ C' ~ I ~ I 1 t <br />` ~ , <br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />I BELEVE THE BUeMITTED INFORMATION IS <br />OBTNNING THE INFORMATION <br />1 r• <br />t <br />Y , <br />I AM AWARE TNAT THERE IUiE <br />ACCURATE AND COMRETF <br />TRUE / <br />/ <br />. ~ <br />, <br />. <br />INCLl101NG <br />SIGNIFCANT PFNALT EB FOR SUBMITTING FKBE INFORMATION _ J <br />. <br />~/. ~. <br />y <br />' . . ~- ~// _ ~~ . i~ <br />~~ I_ <br />/ p 1, I THE POSSIBILITY OF HNE AND IMPRISONMENT. SEE 18 U.B.C. E 1001 AND 73 d10NATURE OF PRINCIPAL EXECUTIVE ~~ <br /> <br />TYPED OR PRINTED U.8.C. 1 191 e. IMrItl.A vtlw tlwAr FbNha ArY YKAd~ !ws IO m i 10,000 <br />.nd>mvhxm bweF+nwlr a/errw~Frlemondu Andb rArA/ <br />OFFICER OR AUTHORIZED AGENT <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND E%PLANATIVN VF ANY VIVLA 1IVn5 /F4TNenCe II/ efrscnmems natal <br />r ~ <br />FpA~Failn` 3320-1 (OS- 1 Previous editions may tia used. ~ IREPLACEB EPA F M TAO W ~ OH MAY NOT BE USED.1 , ~ l I , _ PAGE OF <br />