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PERMRTEE NAME/ADDRESS pnaY6i'rWyHsr/Lesulm //O/BE.w,p <br />NAME i+.'~. ~n ~. :!n ~.. : ~'A., ( <br />ADDRESS I~ `~ t ' =, +' '~ <br />FACILITY <br />LOCATION r. d C ~ ''. .. , i s . ~ 1 <br />a _ - . <br />NATIONK POLLUTMT DISCNMOE ELIMINATION SYSTEM INPOESJ <br />DISCH~ R6 E MONRORING REPORT COM91 <br />IrJUZ.:I <br />PERMIT NUMBER DISCNMOE NUMBER <br />MONITORI G PERIOD <br />YEAR MO DAY .YEAR MO DAY <br />FROM t ~ J TO ': 't 1 r: ~ I <br />/~Q`l11 M9J41 I9LJ51 /D1G0TI tlAd 01 /'M911 <br />Form Approved. ~ . <br />- -- ; ~ ~. , ~ ~ ,OMB No ; 2,840.0004 <br />/ .. ~ .~, It ~ ~ : ~ Approval exgi4ee 05-31-98 <br />~.+ <br />- `aL <br />'..i <br />NOTE: Rasd Inetruedaro before eomplstlnp this form. <br />ppppMETER I3 G/e Onlvl QUANTITY OR LOq O /I Ovd Ontyl QUANTITY OR CONCENTRATION 1,10, FREDUEHCr SAMPLE <br />(32.37/ 14653 15461/ l3B-IS !4653 !6461 EX OF TYPE <br /> <br />AVERAGE MAXIMUM <br />ITS <br />MINIMUM AVERAGE MAXIMUM UNITS <br />!sass/ Maras <br />16463) <br />lfi9-701 <br />. .. .. t:: Ts' SAMPLE ... '-~ ( .~) ~-... ;~..w.. i' .~ <br />I <br />' ~ l- <br />1 <br />t ? <br />_ ,. MEASUREMENT ~.. - + j <br />~/ ., ~ 'I I <br />._ <br />.. PERMIT ._.w ._ , <br />.c:;.•,..-,. t. <br />...i. ;. F`!3:i .:'~ v <br />.. .k~".t:r:;: ~ <br />~ ::'>: <br />',:rcr-::::.^0~.: <br />-- . ~ <br /> <br />' <br />:': i. .. , F J ~ o : '. ~., ~~ . .REQUIREMENT :. ~ ~~ i !r :i :.'. `~d :{ '~ ,. - . ~.:::~ ~ ~ ~ <br /> SAMPLE <br /> MEASUREMENT <br /> .AERMIT ~ ~ ~ <br />:.:.. <br />. ~~. <br />` °~~ <br />~a~._~ <br />' <br />~ • <br /> <br />. <br />~ <br />~ <br />: <br /> .REQUIREMENT .~. .. .. <br />.... <br />,.:: '4#r.:. ... <br />. . . <br />. <br />.~ <br />.':.. <br /> SAMPLE <br /> MEASUREMENT <br /> 'PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> .REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> .PERMIT <br />,. <br /> .REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ~~ PERMIT ~~~ <br /> :REQUIREMENT ~ ~~ ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> .REQUIREMENT:: .. ~~ <br />~ <br />~ <br />~ <br />NAME/TTTLE PRINCIPAL EXECUTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED MD <br />MILIM WITH THE INFORMATION SUBMITTED HERE <br />ASED ON <br />MD / ~ <br />~` i TELEPHONE DATE <br /> IN; <br />B <br />MY INDUIRY OF TNOBE INDINDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION, 1 eEIIEVE THE SUBMITTED INFORMATION 19 1\ <br />I <br /> <br />TRUE, ACCUMTE MD COMPLETE. 1 AM AWME THAT THERE ME <br />r; i <br />- }..~-`~-- ~ <br />~, <br />. I <br />. <br />t <br /> aONIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING ~ <br />~ <br />,_ I ~_ / ~ . <br />~ <br /> , <br />THE POSSIBILITY OF RNE MD IMPNSONMEMT. SEE 18 U.S.C. 1 1001 MD JJ <br /> <br />BIONATURE <br />F f111NCYPAL EXE <br />UT <br />I ` _ <br />I <br /> <br />TYPED OR PRINTED U.S.C. f tats. IArWtlaa uMr elrro m1wP nIFY Neb/a rirwaW ro dI0,000 <br />.ns or nl..inl.n irW/eenr/IrIrWMrwarl e11.e1wwst.ral O <br />C <br />NE <br />OFFlCER OR AUTHORIZED AGENT <br />CAPE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />V V MMCn I J An V CArLAnA I lun VC ANT vl V LA I was lrrnsrann sn srtscnmenn oars! <br />... ~, ~ - : !. ..:. L b _ . ' ! .. .. ,. l l i A. (7 :. J f 7 ~ t ) 1 ,: Y .{ r : i .. ~ .. ~ l: r : ~ 'i J P ' { (. (` ~ i Tall . r? . <br />FPA Farm 3320.1 (08.961 PreLtous'edieone may be used. IREPLACEB EPA FORM T40 WHICH MAY NOT BE UBED.1 (t IT ~ ;1 V / 9 9 +) ~+ t u- I) ~ Z 3 PAGE Y OF <br />