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PERMRTEE NAME!ADDRESS (lrrbi Fadrry NaWLoeanm llDlQGrm) <br />NAME .. .. ...~ ~'~C t•;,.'; <br />ADDRESS i) •:.I. « .. ii e <br />FACUm <br />LOCATION ~ ,.. 1 , ~ ...: ,; , 7 '~. 1 '• 1 5 <br />n 1 . • , .. ~ .. i. 7 1 1 .1 .- <br />NATIONDISCHAROEDMONRORINti REPORT lOMR1POES) <br />1-161 17-I9 <br />y PERMIT NUMBER DISCHMOE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY ~~ EAR MO DAY <br />FROM il, ~~ 'f < <br />neon . ro~oel preen na_om ranan <br />Form Approved. >< <br />-. r ; _ ~ ~ ~ z ; , r 7 OMB No- 2040-0004 <br />1 , w .I'~ ApproveieKgi~ee OS-31-88 <br />- "'' 4 :, ~ <br />t .,):. <br />"-:: VU i i:il Hatt 1, [: ~__.~ .. <br />NOTE: Reed Inetruetlale before completlnp th4 fam. <br />PARAMETER !3 Grd Ontyl QUANTITY OR LOAD Q <br />!~ !~ Grd On/yl QUANTITY OR CONCENTRATION Np, FRECUENCr SAMPLE <br />131-371 !1663 54671 <br />'~ 38x51 !4653 51-61 EX OP TYPE <br /> <br />AVERAGE MAXIMUM 5 <br />MINIMUM AVERAGE MAXIMUM UNITS <br />111.1]! MN.VSIS <br />Iµ55) <br />I5&70) <br />.u..1.'0, ~ .-, <br />:.LS.,.,ii .. ,. SAMPLE <br />MEASUREMENT <br />~ <br />.. ..^:.r'# <br />~~~ <br />fi iJC~ y~~ <br />/ <br />1 :7) <br />~.J <br />'f~li <br />~l"J <br />/.~:.. ,, U ~ PERMIT "..~_:=,.~ <br />~ rc##C~~i#~.. ~~~fi^r;~~ T.yPI"P.In'E~:I`. ~ ~%'~:.P <br />`~?'f': ~ " TrtL*i ~ ;';:3F.i::.. <br />.' c' ~ ~ .... 1 . ~ V a ;. REQUIREMENT ~ ~ . <br /> <br /> SAMPLE <br /> MEASUREMENT ~ ~ L~ j -~ <br /> PERMIT :~;F <br />~~ <br />•~:~ ' <br /> REQUIREMENT „ <br />.. <br />: `6:.. "~ . <br />~` . ~'~~~ . <br /> SAMPLE i <br /> MEASUREMENT I <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 />NAME/TITLE PRINCIPAL EXECVTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLr EXAMINED MD <br />MILIM WITH THE INFORMATON SUBMITTED HEREIN <br />MO BASED ON I <br />' <br />, TELEPHONE DATE <br /> ; <br />Mr INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR . ~ <br />J <br /> OBTNNINO THE INFORMATION, I eEUEVE THE SUBMITTED INFORMATION IS <br />TRUE, ACCUMTE MD COMPLETE. I AM AWME THAT TNERE ME <br /> <br />SIONIFICMT PEMN <br />TIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING r <br />~ <br />~ ~9-~ ~ <br />~~~ ' <br /> <br />~ <br />, <br /> <br /> <br />I <br /> <br />t <br />)~ <br /> . <br />, <br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE to U.S.C. 1 1001 MD 35 / <br />eION <br />Of <br />I <br />T I <br /> us.e. 1 17te. fAwr61.• uMe. N.w mlvn. rrrr heA.d. Firrr• w ro t road A <br />URE <br />PR <br />pPAL EXECUTIVE AREA <br />TYPED 011 PRINTED ms>rrrrhnm inor/ArnMnr e/Mrwwn errlmtluW SYFer+l OFFICER OR A ORU!ED AGENT CODE NUMBER YEAR MO DAY <br />~.ummcrv r a nrvu cnrL.nnn I Iun ur nn r YruLn r Iuno lrtererence ui srtscnmmu reels/ r <br />.~..~ ~-..•I !.,.. .1~I. Y.. ~~ d. .' . I. ..1 dom. ;~.iL L. ..I ~ ~ ... .r ''? ~=~.1Y ti•'1 i:C~ Y, , <br />_...:i..:: ~.,,~. ~.:;!. LIMI~i F.i~r_. c~ ~ >:UY-,,24,1`[ P.:cCil ';vr'..1'. .. ',T „I~ ~ -.. ,'u^' ;.i :..... ai! <br />,ti:~nS - Iu. TOi 7'IN I'~.1 v;l N':-:vF 7_ -I-C <br />EPA Fam 3320.1 108-861 Prsvioue edltlone mey be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE U6ED.) N U D ' S / 7': 0 `J 1 4- 0 9 2 3 PAGE 1 OF <br />