PERMITTEE NAME/ADDRESS (IM,6 F.eeiry NwWLxanen dDl>linnq
<br />i
<br />NAME ~ . 1 ~ ~ '.:o .,
<br />ADDRESS N `;'+ '~. 1 !'. !1 C 4 F
<br />' 1311 3.~..,tw~...1 a.Y
<br />~'~`+,'!f •. ~ E v t. ,, s v ~ Ile ?" 7"RTJ'?+t+ I AJ
<br />FACam
<br />,_. _.
<br />LocAnoH p p, _; ; 1 q
<br />~. L. Ps...~ CD H1J41 F
<br />ATP(+: •, /'°NF;?AL N^N.
<br />Form Approved.
<br />u!, ., t\FF ~r1 ": '\ `,1 E•'1~~'NP~~Q40-~4f ~~^F
<br />(S(:°R Sr.) APProvel~xpile~p~-31-98,
<br />r - FI`?AL
<br />`•r1:nR
<br />NOTE: Reed IrwtructltNle before completing thb form.
<br />PARAMETER l3 AYd Ontyl QUANTITY OR LO' !4 Urd Ontyl QUANTRY OR CONCENTRATION NO FREQUENCY SAMPLE
<br />/32-371 146-53 !5461/ 138-451 14653 1546/1 EX of TYPE
<br />
<br />AVERAGE MAXIMUM
<br />MINIMUM AVERAGE MAXIMUM UNITS
<br />/sz-a31 ANALYSIS
<br />/64681
<br />169-7o1
<br />PN, SAMPLE ?:tr^:^ .... .,-..^ ( 12)
<br /> MEASUREMENT
<br />:lOq~!!) j () !1 PERMIT rCVk.410i4`
<br />~ ~OE>y!p!~:Q1.-:..
<br />::
<br />.. C^-;` ;i.:±'':::.
<br />
<br />~~ ....:. O$'/.`~tb'Jlf
<br />
<br />~ . VrQ:..
<br />. ~:z:RI.. Ty:l'_^.,'
<br />I - ,
<br />F:F!'L 11:4T REQUIREMENT '...:.•t'. ~.: .~
<br />~
<br />~OLIUi, TOTAL SAMPLE 'xF?-~ ^.:rgxx a400 . ( 1 1)
<br />.i U 5 P ~: R J "r li MEASUREMENT
<br />OUtiiU I 0 U :...PERMIT r.^ir,:e:e atf!eKixa tr:-~ O,y :... ..
<br />..O1k.e .....:.:..... .:.:....
<br />:.;
<br />78 .:.::r ..:
<br />R
<br />F-F/ ~;vqn
<br />%: YF-LLl°9T ;ROSS YAL~1 :REQUIREMENT
<br />
<br />.. . ~ CyF^4
<br />','Qfla ~YG
<br />- .:DlliY:?!' :tIX
<br />R!-/t.
<br />MhPtT
<br />~i7L: U:;F 'S?1'*L°ARLP. SAMPLE ..^7•;`k o-a#aa araaar• ( ?~)
<br /> MEASUREMENT
<br />'J')'•!1 `I 1 U 1) ~~:~~PERMIT
<br />
<br />' ,. :`5 F^=t.= ~7 R'Sd~r -
<br />^ -~~ :=:'1R4Qt~.:.:~
<br />
<br />~
<br />~~ ex;Ya%:1 ~~4t ~
<br />
<br />::
<br />.......:
<br />~-~~-
<br />~
<br />
<br />:~.
<br />~
<br />.:.:. . .. H~'P ':?1:^
<br />rFFI.!1~Yf :R7S5 VAL;I REQUIREMENT .. ....,_ ~~: :';..
<br />::
<br />.
<br />LN )Y, TOTAL SAMPLE fr.. :=4S :: ~: $
<br />~'~. ( Zq)
<br />(qj pF) MEASUREMENT
<br />:Jji!'a-I 1 0 0 PERMIT ~:CG^.^. ,ray„ t-»~Ci+•:: 3.5 .. .?it7.~ '1C1:'/ 'RAT'
<br />;vF! Uh'`, I' :;ROSS lFL.J .REQUIREMENT ~ :: a-xc i4i1>z l1V ~~ ..D JI ~~L~T~ MX "!:/L 'l C/N'*.
<br />!'.. A9? ': (fRA$F: SAMPLE +ppr;r:.~^ ^a:'Gti:'e ...#.`- 's'c.'•Ct4' ( la)
<br /> MEASUREMENT
<br />'i 1', :) I 0 U PERMIT :+n4"1t'¢.!aa :. ,: vAt3g ',.q 5.. .; r.~..VY??'.3'rx ran##4#. '.~~~~ ~:~~
<br />~
<br />~~ 11 A1T1 ':p Ar.
<br />''F'r'Li:F.'.° :R75S YPLrI ~REQ4IRENIENT t•-;--j; ~ ~ ~.
<br />.. ......
<br />.. ..:
<br />.
<br />.,, ~ / ry.
<br />i'i."'a, I`! ^DNDOIF ,1K SAMPLE ( pj) .._r~.... ~.ts;AAr.
<br />LII ~•il rr, :;A TR'r: !?L' PL4~ EASUREMENT
<br />>'l:~',I` j D () PERMIT. ??P9R'[ RP.P'i~RF ,.,,;.~.sK yT:::;esXn: afi.~a0#t` tRx^ p~vi IK^^A
<br />-°PI, 11 f•"~;' ,iROS~ YRLp :FIEQUIRENIENT J7AA A1~G ~DAILT yY'. R•';C :-'til:
<br />ilL 17'i ,%J t:A$`' SAMPLE r?0%4^ ( U4) ~'~a^'°' "C Y"S: ...
<br />V I 'i I: 4 1. MEASUREMENT
<br />••f Jh•, j U II PERMIT.. .C .t.'T :.R E~Pp'R.T c~;=7 "~T't ft flla-. ~ ~-:. .:n%n .. r u
<br />i~aR
<br />' i'F'L.I•"I',~ .:R75° VM1L. IJ ~RE.QUIFtEM.ENT: ~.. ~. ~~. .t ~R §.T, 15~11..~;~ V'l=0 .. ~ :•:~~~k
<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PFNKTV OF LAW TNAT I NAVE PERSONN.LY EIUMINED AND
<br />AM FAMILIAR YgTM THE INFORMATION SUBMITTED HEREIN
<br />AND BASFD ON TELEPHONE DATE
<br />
<br />q `
<br />~"~+' ;
<br />MY INQUIRY OF THOSE INOINDUNS IMMEDIATELY RESPONSIBLE FOR
<br />OBTNNING THE INfORMATION
<br />I BEl1EVE THE SUBMITTED INFORMATON IS p
<br />
<br />!( I
<br />/ 1
<br />` ,
<br />TRUE
<br />ACCIIMTE AND COMRETE
<br />I AM AWARE TNAT THERE ME , '
<br />~
<br />~
<br />'O '\ \I\-1
<br />
<br />
<br />1-l h r\ 6 C. ~'
<br />.
<br />.
<br />SIGNIFICANT PENILLTIES FOR SUBMITTING fN
<br />SE INFONAATION
<br />INCLUDING
<br />
<br />f
<br />~)
<br />pL~_
<br />7
<br />,7a
<br />GPI -1
<br />O
<br />I L
<br />
<br />y .
<br />,
<br />THE POSSIBIOTY'OF R
<br />E
<br />D
<br />PN 1 - 0 1 1 I
<br /> N
<br />AN
<br />IM
<br />SONMENT. SEE to U.S.C. f 1001 NID 3] BIONATUIIE OF PRINCMAL El(EC
<br />
<br />
<br />TYPED OR PRINTED
<br />U.B.C. f 131 e. R°Yll.le.. I/IAA dnr .btlm. nuY I'1[AnT1 A'IrF W ro 510,000
<br />rlsonrrirllnr iryv/mrwtW Mtww,emarNa rtl6Yfrsl IlI1VE
<br />
<br />OFFICER OR AUTHORIZED AGENT
<br />AREA
<br />CODE
<br />
<br />NUMBER
<br />
<br />YEAR
<br />
<br />MO
<br />
<br />DAY
<br />l-UMMCrv ID ArvV CAT'LXIYAIIVro VT ANT YIULAIIUIYD //FB/6/IDCI N/eRDCOnIMr9 DI/e/ '
<br />• L ^L• a ~! \r!a p -ry'\O nor. r
<br />/. '.Y Y A.. l'~ C". ',./,;^''.LY A•/:. 17': .~C,1-: p'. aTL :"'F' - I. .1.L•, P. •l, ._
<br />r
<br />1^ ., !, .,, 1,(~EIT'i v!(., ~/:, 'N .qIY°^, A'.p S; rl,:grlL. '!LI'1<. -.I'1im.; .u:..I"'r c,); <=7rfY' ~:J,s+ rTR('TD ..Y...1~._~,
<br />='ll Elf: 1(tIT u1L1 q: 7ijVF^ P7t )1 x/94 )!1114 DYE^7D PVANT-CXP aIT lir TT"/4'IPhPI r4 PGA F vL'lTN NT • E Z ^7•
<br />EPA Fwm 3320-1 108-55) Prevloue edltlone mey bs ueed. (REPLACES EPA fORM T30 WHICH MAY NOT BE USED.1 00 011 V / 9 6 1 2 ] 7 -12 71 PAGE PF
<br />
|