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PERMIT'IEE NAME/ADDRESS (Adi6 FsWry NaW/<cmru dDls r+u) NATIONAL POLLIfTANT DISCHMOE E <br />NAME _ a DISCFIAROE MONITORI <br />ADDRESS ,y "r'.: ;Lv y[vv.- :, ~.,o-~tti-4 ~~,/,fC 1-16/ <br />+ °~ "' + ~ PERMIT NUMBER <br />lit T3t;,,rtwd.9 Dc:~c <br />~~m~. <br />FACILITY ~ v v. ~ t Y N e L Z N y 1111 MONIi~ I <br />LOCATION ~ _ ~ ~ ~ YEAR MO DAY <br />Ac:°;~oN q. L. ~¢„ ~~ aj7g1 FRO 7a Ou i <br />dT:'~: 3`i~r+~i, u+-y^_' •7~VCDer w=o. r1o-~nvz~alnuc - <br />FoRAnpn Approoved. <br />v!r•; ~~^'•:, ~rl 4~'4Appo ells%~e90~31-98 <br />(•'R°r% SF) 11115 <br />v - F1"~i. ~ <br />~rNr,<~ <br />9'~ ~(: In r: ~: •,r ~,r ;r4J~Dr!r '.max/' yq. ;: <br />r~r.~n v6aa1 rsa3n '.NOTE: Reed InritnictlarN bBi«~eln~le+inp thb form. <br />PARAMETER l3 0..d Only QUANTITY OR'LOADINO' 'J OnIYI QUANTITY OR CONCENTRATION Np. FREQUENCY SAMPLE <br />131-371 106-531 154-611 I3B-15 /oE53 I5~-6/ EX TYPE <br /> AVERAGE MA%IMUM :UNITS MINIMUM AVERAGE MAXIMUM UNITS /sE~sal MAiY515 <br />/6I-6BI 169701 <br />r•ll SAMPLE :ZR~^'-Y O~z: C'?; r :Cr.., ~ ~~ <br /> MEASUREMENT .. <br />a <br />UOIUU ) D PERMIT RT)ts Rail : <br />.. .. :it~l~q/rtX. a^::: 5.5 <br />: <br />~ 7011p-'"f4'~ <br />. <br />~ q.{} ~'F"'L <br /> REQUIREMENT . <br />..: <br />::' ; <br />:: <br />.. .. _ <br /> ~ ~ _ <br />OLLiIj+ .:?')TEL SAMPLE .:tt:-G~: 0:046' ',r.2C.11t191 ~~ ( ?4) <br />51"~ P <br />' <br />~ <br />~ MEASUREMENT , <br />^ <br />~ <br />V i) <br />i <br />: s <br />UOb 30 1 0 0 PERMIT a;... <br />".LTSn ~ <br />^tt,c .-0'+ <br />3;: ~~ .....'T~. <br />#1A4 <br />,~ . <br />:cel. ~ ... <br />... _ <br /> REQUIREMENT <br />~ _ <br />~ . . <br />7HJ(Er T1I':1L SAMPLE .t. •.:::e ¢i;g p. .;; n„ ~zRlti#~ ~ ~ ] I) <br />(A'i P^) MEASUREMENT <br />~ <br />.)j.)4 `r t U U PERMIT ...... a.yrt <br />.. ,. ,. . :,:.....::; <br />~.. ~~.: <br />„ ~. L. rr . ~.., I REQUIREMENT ~ r_ ~~ 3: :. <br />1~~ <br />~ <br />~ <br />:. T <br />)iL k"7 ~) ';9 EASP SAMPLE ;:: 4.^F? ... U .8.^.... ~ CO <br />OIIFfi ( t9~. <br /> MEASUREMENT <br />.; )•i .:2 1 D U PERMIT ~ xr: r1 ~%'S ;~~:~><`-# Z:~^ :a:x#vr' 4~?!#01~~ Q. ~: <br />'1 :T't7 i. :gt, ". <br />' F' ~ I,1 r' i T "' REQUIREMENT _ <br /> <br />~ : <br />r . <br />F!„)4r ['1 COND7 [T ;lq SAMPLE ( <br />n7) ... :;: r, 3'r'k C47r40R <br />','i :r .! T!t :'iT.~Pl1T ^Lny MEASUREMENT , <br />ti'!!t',U 1 0 U PERMIT.. R~PO'aT 4f:?OP,T fi:~at..,A <br />4M:•.tR'tit~ <br />'~'G9ixktafi • <br />•04C <br />~L!><.~FL ~ <br />TRS^S' <br />f•~ r .: F• I .REQUIREMENT <br />..., ~ :. r „ <br />q : 1'r <br />YT r:3 <br />)IL %.`70 u'iS h:~°+F SAMPLE ..~G:`r:v <br />( '!U) <br />:~';;~~'~" <br />":'L::k ~^^ <br />.. "': ~'F+?;: <br />YI`.USL <br />MEASUREMENT <br />';U i)'>•, 1 D U ~. PERMIT~~ 00.^~~a... RFP~3 R~T R'.-1 ~ z=r+v; 'r ^'t::C~~~~~~ ~ 4:-:g:C'~ C^G ~$vrT.Y T~'!nf <br />r. h'r' L J F. •! : G D V 4 REQUIREMENT. „,I,. _ ~ ~ ~ : .,~ <br /> SAMPLE <br /> MEASUREMENT <br /> ~. PERMIT <br /> .REQUIREMENT <br />~ <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER 1 cERnFY urIDER PENALTY of uw rNAT I NAVE PERSONALLY ExAMM <br />AM FAMIUM WITH THE INFORMATION SUBMITTED HEREIN <br />MD BA ED MD <br />SED ON TELEPHONE DATE <br /> : <br />MY INOVIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR v <br />A L• ~p-+r4 <br />1 OBTAINING THE INFORMATION, I BELIEVE THE sUBMITTED INFORMATON Is <br />TRUE <br />ACLURIITE MD COMRETE <br />I AM AWME THAT THERE ME , <br />`~J r~ /rl-r <br /> , <br />. <br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING E /VI" ' <br /> <br />}~~ h h F f <br />, <br />THE POSSIBILITY <br />F fl <br />E <br />P <br />$17 <br />O I <br />Sbl-~ <br />TZl G <br />y ~ <br />Gh <br />1 v <br /> O <br />M <br />MD IM <br />NSONMFNT. SEE 18 U.S.C. f 1001 MD 7a SIGNATURE OF PRINCIPAL EXECUT O <br /> u.s.c. E lets. rA.,.,sv. r.w. eLw mnm. m+r NcA.J+ n,., w ro sro,o0o A A <br /> <br />TYPED OR PRINTED <br />.ns armunx.n inEVlsmwNWNw..nemonrhs rw6rwal <br />OFFICER OR AUTHORIZED AGENT <br />CODE NUMBER YEAR MO DAV <br />GOMMI.NIS ANU tAYLANA ZION OF ANY VIOLA 710N5 /RB/B/6/!CB a//efrsChmenis hBlBl <br />iil DAY AYc'iAGr•' [5 4[a'1 _:)" v1NTd LY IIVIi• PII°['.f~ P'?PI"~• 'i r'n•+=i'•~i)• f1IL P. G3ERSE - Ter ?.:'.T.DB P• 'T• <br />lv J <br />EPA Form 3320.1 (08.951 Previous editions mey be <br />USED.1 <br />