|
FERMITTEE NAME!ADDRESS (deY1F.tl6'ryN~N1«allm IfD~irwl) NATIONK POLLVTANT DIBCHMOE ELIMINATION SYSTEM /NPDESI
<br />~ FOrm wppl..•a..
<br />NAME DISCHARGE MONRORING FIEPORT DMRI
<br />ornBNo.2oao-oooa
<br />BOAia RESOtIRCF;S LIt1ITED n-rfi n-rsi I N F L U F. I T K° A S U p E ")1~11~avcAl axpirea 05-31-98
<br />ADDRESS
<br />AO~I~ N[1 1 R y0 1 REST tlINES (S!.IAk iC) 12345
<br />P.J. BOX l4 A_J I ER asN GEN eER
<br />f - PII'AL
<br />FACILRY PAON LA CO B14 29 ~ ~ ~ MONITOR G PERIOD t1IlOR
<br />UGd Ia' RESOU RCE9 LIFtITED AR MO DAV YEA MO DAY
<br />LocATION
<br />-
<br />FROM
<br />T O ~p2 r~ r~7 G~-N~pC~ ~__ R
<br />m~BU^ynTF
<br />f
<br />OTE
<br />`IR1
<br />C1
<br />R
<br />BH~TWr
<br />A60
<br />U
<br />O
<br /> "
<br />l7P1/l !7 -I31 l1b76/
<br />" ! & ,)r 11679/ /3D-3f1 c
<br />:
<br />a
<br />1
<br />^ t
<br />I
<br />u
<br />n
<br />orm.
<br />PARAMETER IJ Grd Onfyl QUf} ,: TITY OR LOADING N Card OMyI :hUANTITY OR CONCENTRATION
<br />' ~ NO, R1EpuENCr SAMPLE
<br /> I1639I 16.f-BIl !1663
<br />!3B I6F6/ % ov
<br />/3Z-371 E AN/~LyS19 TYPE
<br /> AVERAGE MA%IMUM ~ UNITS MINIMUM AVERAGE MA%IMUM UNITS 9fl~p !6/I-6B1 I69-7D1
<br />Jioo, s-DAe SAMPLE ~ 2f,) +d461Q¢ ( 19)
<br /> MEASUREMENT
<br />(20 DtG
<br />C)
<br />.
<br />U031U " ~-- ~
<br />'REO)JIREMENT
<br />>°'< ,. .
<br />_AI:BAttT
<br />YI,l~T~571~-.i.-
<br />M,ISItgF11,~~1k
<br />RFR'11~'k'
<br />Q~"T3;i+tiik~r
<br />~~~.
<br />.:IJ!fP~
<br />
<br />SAMPLE
<br />u
<br />it
<br />Lr
<br />"i
<br />..,.. v... ..~
<br />:..:
<br />
<br />...
<br />
<br />
<br />.::
<br />
<br />
<br />- SAMPLE
<br />~~~ MEASUREMENT
<br />' ~ .., ,..
<br /><,;~i':'E ~RMIT'°r'::.:~r a,, .::~~~~~;~~'2":.~:r.::.-Z ~::<.:.;.c:.. ~~~:~:::-:<'.,'::. y ......::.:........
<br />~~..p R~ ;a ,, z s
<br />s F
<br />A;iE1RE(NEN7 ~ ~ ~ :.. - , ; CI ::< ~/".
<br />v,„ ,...:, .. ,:
<br />-, - ...<.~: .,~.., :., ., : , r is "a':
<br />~EdUIREMEf(T ~ .,:. ... -'~ ~ _~ .a. ~..: ~.: •• ~ -.rz,. -.;~ ~ ~.. ..
<br />j ... .. ..~:.: ":.w
<br />REdgLR.EMEF);f;:~t>:..~:.::.:.:':4'::~;~c'>~~`:'~~'..:"~i?'`:;3)>~.a :..:5 ,.. ::~. ~.::::.~i :. .: ...:....:....:~.:::..:~:.~.;::>^~:::.::~:: i:..::;, .::.:::::.. ....
<br />.....:.:~.::.;:x.:.:; ~ .:::..:.:::..: .: .:.::.:.::.:r.:,,:.3..; ....::.:: ,: c.
<br />::::..:.~ ..:... ...~.:.,:z~~. ..:., s :~ :.::.:.:::....::..::.:.:.:: <.:
<br />NAME/FRLE PRINCIPAL E%ECUTNE OFFICER I CERTIFY UNDEN PFNKTY OF UW THAT 1 HAVE PERSONAD.Y ExAMINED AND ~ TELEPHONE DATE
<br />AM FAMILIAR WITH THE INF011MATON SUBMITTED NERDN; µD BASED ON
<br />? L(/r ~~/I~+YI /,'F~r, .~ MY INOUIIIY OF THD$E INDIVIDUAL3 IMMEDIATELY flESPON5IBLE F011 ~ ~'
<br />R OBTAINING THE INFORMATON. 1 BFUEVE THE SUBMITTED INFORMATON IS /
<br />TRUE, ACCUMTE µD COMPLETE. I AM AWAKE 7HAT 7HEflE ARF
<br />' 1 SIONIFlCµT PENALTE9 FON SUBMITTING FKSE INFORMATION, INCLUDING _
<br />V ~7 (/nl na '~ 1Q/ I ~ THE P0591&UTY OF f1Nf AHO IMPIY90NMFNT. SEE 19 U.S.C. E 1001 AND 90 iIONAruRE OF MIINCMAL E%ECllI1VE ~~ ~ ~ ~" ~ _~ ~ ~ r 1 ~
<br />U.S.C. E 131 B. IIVWtlr. YMa Uvw mBIFr. my iKA.d. NNS Iq ro f 10,000
<br />TYPED OR PRINTED .ne p~nwb.nl ilprlarlrnrlr W bM~n S manNS rd s nra/ OFFICER ON AUTHORIZED AOENF ACARDE NUMBEA YEAR MO
<br />" C.gMMENTS AND E%PLANATION OF ANY VIOLATIONS IRa/9rsncr sl/attsMm~nu hcrsl
<br />~t. LU~'NT SAhPLES iiUST. ~+:.- COLLECTED F. ANALY2F.D 1.]NTNLT AY'1 RrPOR7ED J"),1fiT°kLY Ki;::it?"L°'S?^.~ .t4rpHER A!I
<br />~" ,'LU~NP D~~bSCHABUF, OCClJHS. ORGANIC CAPACITY = 25 LAS AOD-5/DA T.
<br />orm 20.1 (YiE'~ fsNOps, B~e'd used. IR LACES EPA FORM Td0 WHICN MAY NOt BE UbED.) PAGE OF
<br />L -.,.r-y ~ ~~ ~ ~~ ~ ')~)2-3 ~f/4 i) t JI -lri .71 1
<br />- ~ ~~,.
<br />t
<br />
|