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PERMITTEE NAME/ADDRESS O+aYb/,sYlryNaar/Lonllaw /°~.rU NATIONAL IOLLUTNIT DISCHMOE ELIMINATION eVeTEM /INPDESI <br />NAME ~ pBICNAROE MONITORING REPORT OMRI <br /> <br /> <br />- ~ ~ 1 ? 11 I~ `..~ ~ ud.~ l~r ,` 1c PERMIT NUMBER CIBCHMOE NUMBER <br /> <br />FAaLm ~ ~ " <br />- ~- ~ ~ SRJ y~i q MONITORIN ROD <br /> Y AR MO D Y YEAR MO DAY <br />LOCATION, ~~ _ ~..-, .I <br />~ <br />I L <br />A <br />' .~~ ..; <br />~ FROM TO <br />F r "'. ~ .]'S. . <br />. <br />. ~ .. i L ~ 17 n9.a31 196767 I7B•771 128.791 IJO•afl <br />Form Approved. <br />- ,. - : ~ .... .• .~ ~ - OMB Nn,,!204Q-0004 <br />r ~ ~ , ;„1 Approve4s11p1fse~05-31.88• <br />(`.'_ ,t , <br />- NOTE: Reed Irutruetlorr bet oompletlnp thM form. <br />PARAMETER (a QrN Onryl QUANTITY OR LOA (4 !SN Onh1 QUANTITY OR CONCENTRATION plp, MEOUENCY SAMPLE <br />IJ7•a7/ I 69 66e1 3B-!s tB•sJ BLS/ EX MALYWB TYPE <br /> AVERAGE MAXIMUM ITcy MINIMUM AVERAGE MAXIMUM UNITS 1ep-aal (s1-sBl lss7ol <br /> <br />r.: SAMPLE <br />.. r: r: r : ~. <br />. <br />~-' .... 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Ii ~,,.~ ~..1.: ~ ~,AL.I. :REQUIREMENT: ':~: ~. ~:~~ .-:.:~:~ ~~.;.i:llr,~T `!.liK.: 1;•~r-n ~ .. . <br />NAME/TRLE PRINCIPAL EXECUTNE OFFICER I CERTI FY UNDER PENILLTY OF LAW THAT I HAVE PERSONALLY EI(AMINED MO <br />TTED <br />EIN <br />MD BASED O <br />~ TELEPHONE DATE <br /> ; <br />AM FAMILIM MATH THE INFORMATION SUBMI <br />HER <br />N I <br />' <br />~\ <br />I I' . MY INOUNtY OF THOSE INDIVIDUALS IMMEDIATELY RESPONABLE FOR <br />OBTNNINO 7HF INFORMATON, I BEDEVE THE 6UBMITTED INFORMATION IS ~ ~ <br />I <br />~ 1 1'-'- <br />~ <br />7 I AM AWME THAT THERE ME <br />TRVE <br />ACCVMTE MD COMRETE Z <br />\~,E~`. <br />" <br />~ <br /> , <br />. <br />SE INFORMATION <br />IMCLUOIMO <br />I <br />MT P <br />T <br />TTING FA <br />A <br />E <br />R S <br />BM _ <br />~ <br />' <br />' <br />fj <br />1 <br />[ <br />I <br />` <br />L .• / I C ~ , <br />S <br />ONIFC <br />EM <br />L <br />I <br />e FO <br />U <br />I <br />L <br />THE POSABNTY OF RNE AND IMPNSONMENT. SEE 76 U.S.C. F 1001 MD as ; <br />1 <br />I <br />E <br />E ~ ~ I ~~ 7-?T ~ <br />~ I ( <br />TYPED OR PRINTED u.s.c. t 7a». (Mra.. Mwr tlwar moms msr bFAd. n». w Is Fr0,000 <br />an/amRainlwr inlvrlet+wlr ere.wFFn tmaeeha an06YSra/ CUTN <br />BIONATUiIE OF PRRYCEPAL EX <br />OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IVNS I/fe)ei~nCe V/ errl0nmenla oars/ <br />~ a <br />r., .r• - r '1 r~-n <br />w <br />~ <br />i AVP $'T". ~• .. P:~r <br />! <br />~ <br />' c•lr _ <br />C.11 YVF; l!°'i; PD..t•T r. <br />. <br />` <br />, <br />~ <br />a ~ ._ <br />. <br />' <br />tr r st: <br />~ <br />~ ~ ) ur yr^t -)''T-'GL TA <br />T' F'!E: TtC ptl }. vY'c-~ _ <br />orm 3320-1 ICS-96) Previow editions mey be ueed. <br />EPA ~ (REPLACES FPA FORM T<D WHICH MAY NOT BE USED.) ran U 54 / 9611.1 3 ~ ~ 1 PAGE ±OF <br />