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PERMITTEE NAME/ADDRESS R.~4 Fxd~ry Nadferanm dD~r.r) NAl <br />NAME ::k$C~IDE 2JAL ~D,9PA;JY, LF2• <br />ADDRESS E .q $ T:i I D E .'I C 4 F <br />1~.:J. B:)K 101 J;~7 W <br />5A 1 AhPD4[J T:t 19271-1 ~1/ N <br />FACILITY EA.,[':.ID~ .DAL ~J"FA~IY, IN., 11J M <br />LOCATION,- <br />ot~l' <br />2D SIi~1.T. U FRgj1A <br />3TP': cap. ..u v., r.~-tc a_oer a• ~ n <br />It <br />LLUTMT DISCHMOE ELIMINATION SYSTEM 7NPOESI Form Approved. F <br />:HARGE MONITORING REPORT IOMRI <br />' <br />'" - <br />" , ~OMp No. 2040-0004 ' <br />!Z-7sl 77-791 <br />n T i ` <br />= <br />~ ,• '.iD ~ <br />C~ ''APProvel diplres 0531-98 <br />~ ?3u; / <br />AIT NUMBER DISCNMGE NUMBER r, _ <br />:.IL ~ I <br />MONITORING PERIOD h I g ~~ -"~ <br />MO DAY YEAR MO DAY <br />UI )L TQ .,_ Js 51 aac •t r, ;?I=:"'I+; ~' . I__Iyy// ::`-': <br />i <br />~ <br />~ <br />f <br />n1-]31 nb15/ ns-vl l4ea91 73x377 NOTE : Raed inetructlorie bs let <br />np thle <br />•EOln <br />orm. <br />for4 <br />PARAMETER 13 Grd Onhl Q SIT LOADING 7t Grd Onyl QUANTITY OR CONCENTRATION pJ0- FREQUENCY SAMPLE <br /> It6-531 1Sb61 ~=- 138-45I !4653 15b61/ <br />EX DF <br />l3Z-371 <br />AVERAGE - <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />Isme~l MALYSIS <br />!sq-sgl TYPE <br />(sg lpl <br />PH SAMPLE ACC X:1 ~r:h? ; {~'.~ '+ ( i )) <br /> MEASUREMENT <br />UU40D 1 6 ) PERMIT ?-X; {1RC %#t1Gfx r, .'v;= 5, j +:#4.X i; 9.U iEEKLY CNSI'~: <br />EFr LUt.NT ~^755 pA ;Iw REQUIREMENT YKI: ~; y 1IE F •e. r IM cu <br />SDLIUS, S;T 1'LFA3LE SAMPLE :0 ~.t t". ~•:`•X?0X ?. #il:k4 .-~ ( 7`i) . <br /> MEASUREMENT <br />U0~l5 I D U PERMIT r#x?#G t~#C?r t S##??0 -::.?{~; >r' O.li RCF,/ :A~LC. <br />£FFLUF.li1' ~R7, Y ~(,^p REQUIREMENT =YytO T .* wr / rn <br />;JIL 4NG ;i :i ',A ,4; SAMPLE ~:';; j: .XYy CC?•tG~ OF:: ~%::+ {:~ CG ~ I9~ _ <br /> MEASUREMENT <br />J35d2 I 0 U PERMIT #Ix i-'r'!A g. #~Yi-~-r "v 5'+Oa ?G:k ::.;-.~ ~I+?## ~ 2Q ~ <7M2'IN :RA5 <br />t;eF'LUr.'1'f ::k75S PALUE "REQUIREMENT OAR# I Tr MY ~,r r r,o r <br />FLD:, IN ~DNDDIP '1 :; SAMPLE ~ p3j O;~CC•;=;: #>r# ;:a ##?:~;: <br />TNHU TR3ATMdVP PLA Nr MEASUREMENT <br />D005U 1 U D .PERMIT UP?I)ItAL B'cP3CT +fA1l#kl.;+s +-'~tr~ '% =~~IIR:.s~ : ~Rtr'~ °i.EKLY CNSIA'. <br />dFFLU.°.NT :.ROSS YAL'JF REQUIREMENT . <br />"9D.A AY: ~ A nr ~ ~y;"::, ". C[e ~:= <br />:iJLIDS, CJ?~~ SAMPLE #C 0A}-^• 0t1XG~ O;ACCI:L< ..~T ( L9) <br />UI SSOLV :U MEASUREMENT <br />70295 I J D PERMIT rit0#5.0 #P#"$6# ~;x 'X0;1;=t:+z &~.n t: I~C;PURT ~ ~TRLY' ~~AS <br />,FFLUE5T uPJ:iS YA U :REQUIREMENT ±, .}~+r "tlsY4 V MY Mr <br />DIL AiJD ~!i °_q-SE #~C?#4 ~ 94) 7F ,tC:~,`-# ##: ## `v ~~~#:<#^- <br />YI:;UAL MEASUREMENT <br />d4Dbo 1 0 :) PERMIT. #41rR:X,= REPORT ES=1 4#StCtt# {c0,E1 ~ i•##+?111K7 : : ; 1;: ~ IV~':/ 7TiL'RL <br />EFtl.UiiN: SHD35 YAL'JE REQUIREMENT. TMSY R Y NE1= <br />M 'T'H <br />• SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME7TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED MD <br />MILIM WITH THE INFORMATON SUBMITTED HEREIN; MD BASED ON TELEPHONE DATE <br />J <br />/ <br />~. /~ ll~ <br />L MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSieLE FOP <br />OBTNNINO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />~ + <br />/ <br />M <br />f.f/ <br />I AM AWME THAT THERE ME <br />TRUE <br />ACCUMTE MD COMPLETE - <br />~ ` ! <br /> . <br />. <br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING ~ "' <br />/' '~^ <br />~~ v~CM77UL7 ( , <br />THE POSSIeILITY OF NNE MD IMPRISONMENT. SEE to U.S.L, E I(Wt MD ]3 SIGNATURE OF PRINCIPAL EXECUTIVE Ziu ~~~ `~ ~~ ,~ <br /> U.S.C. t 1319. (PlvWltrs IaIINr N.s mrvro. nrY Ycpd. l.wa w ro t 10,00F1 AREA <br />TYPED OR PRINTED .nd nmuinun/rnP+lawwlt elMMwn6monrea rM6rN.al OFFICER OR AVfHOR1ZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION Oh ANY VIOLA I IVNS I1reIerMCe e!/ BrteCAmen is Oere/ <br />SELTLEAdL3 SJLID$ LI"II" aALVED FOG LJ-Y fl, 14-d3 PRt'~IP `_'7FN1' $JnJGC'. BURDF; C;' ?';O~^ n?~UIF°"ENPS 'C <br />PAh"'t I. 3. L. D, Pte. 5. ~TDfl"t+AT54 .'1A~Jq„31EYP PLAN 07° 1-L-3d. <br />EPA Fam 3320-1 (0&961 Previous editions mey bs used. IAEPIACFS EPA FORM T~0 WHICH MAY NOT BE USED.1 ~ PAGE OF <br />27.75/970310-15~~ ! ~ <br />