|
PERMITTEE NAME/ADDRESS RkYiFxWryN~,/Lxnm I/D/p,.w.0
<br />NAME L.Yr~~.u:, _.1r'lr~ 1-,~~r•~n. 2,1 :~~..
<br />ADORES r' V ]uT V:•
<br />tKal„ L;0 nltl~:~
<br />FACILITY t(I.;1VS trl."lt't tLlkr'tIKAI1~N
<br />LOCATIONtKA 111 t0 tilb2y
<br />.11 i., ~11~riAcL w. L./ULLJwE GENERAL Miri
<br />NATIONAL POLLUTMT 019CNMOE ELIMINATON BYBTFM lVPDE$l
<br />DISCHARGE MONITORING REPORT /D RI
<br />1-16 11-19
<br />~ I Y
<br />PERMIT NUMBER DISCNMOE NUMBET
<br />MONITORING PERIOD
<br />YEAR O DAV YEAR MO DAV
<br />FROM TO ~ .0
<br />114111 111-131 /11-16 /16171 l18-191 !34311
<br />Forrfln Approved.
<br />~: ,,i r.,'+t. v I U r11~~ l~0 2040004
<br />~UUn 11n Approve sxprsa0531-88
<br />a ~4'~
<br />F - rliraL
<br />iM i tiUic
<br />NOTE: Reed Inetruetlone before m Ietlnp Mb form.
<br />PARAMETER !3 Grd only) OUANATY OR LOADING II" " lyl QUANTITY OR CONCENTRATION
<br />' ND FRFOUENCr SAMPLE
<br /> (1663 51-61 ~. ~~ ;16:~ /166 I5L6/ OF
<br />/31-371
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />(MUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS EX
<br />
<br />mld3
<br />MALrss
<br />161-eBl TYPE
<br />
<br />16A70/
<br />L, 1L AI'.u 11n1A]t SAMPLE tti##$tk4 i4 ,t,}i•a'~`t%~ #ti~~
<br />Y1~~~L MEASUREMENT ..
<br />04.. c t1 1 U ~ ~ . PERMIT ~~ kAr# .:~.:;4
<br />#~~' d ~:r,.•sq::c:
<br />'' •,: .:
<br />.., ..
<br />E5 1
<br />`#t#~#41..:":
<br />";.:.~t,±a**I~
<br />~>rlv#,~~r.
<br />•tt~;•
<br />F+i~.fc1
<br />I:>I:.t;L
<br />_
<br />crr~L
<br />ni L
<br />t
<br />kiiSS VA
<br />L REOUIFjEMENT ~ _
<br />~~,.:
<br />F
<br />iw
<br />' ..~.:`<: .~.....~.-
<br />,~
<br />r
<br />L.
<br />, ... S
<br />t4 O •f.•~,r at+
<br /> SAMPLE
<br /> MEASUREMENT }~'.
<br />
<br /> ~~~~PER..MIT.
<br /> R..EOUIREMENT~ :°~'~:.: ~:... :: ~~ ... ,:;+., <,:,.. .. .:..
<br />..;~ . .
<br /> SAMPLE
<br /> MEASUREMENT ~ .
<br /> *
<br /> .. :.
<br />.
<br />n.
<br />~: ~~ :~
<br />~
<br /> :REOUIREMENT~. .
<br />..
<br />:
<br />~ ~:: ::::.: ,
<br />:. ~'.:.. .``:
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ......PERMIT ~
<br />~ .....
<br />~~
<br />~
<br />:
<br />'~
<br />F
<br />~°~~'
<br />Y
<br /> ;•;lEOUIREMENT
<br />
<br />.... .. .. .. ~ ~.: ~~..;-,
<br />~
<br />.. .'. ..~ -
<br />~;::>-..:
<br />:'..>
<br />:d:.; :i,::.: i.::' ...:. :i.:
<br />r :. ....:..: .
<br />.,:
<br />a.:.
<br />:::.i Vii:.
<br />
<br />
<br />...
<br />~~
<br />~~~
<br />
<br />
<br />... .::' L,.
<br />
<br />~ ~
<br />
<br />
<br />~ .
<br />
<br />
<br />
<br />
<br />~ ~~
<br />
<br />
<br />
<br />
<br />~ ~~~~
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ~:~ PE~IINI7';:;~a
<br />REOUIREMENY; ::..:......::.. ~
<br />;::~: ;:~.. ~~ ~ . ..:.. ; .
<br />..;~ ...
<br />.
<br /> SAMPLE
<br /> MEASUREMENT
<br /> .. ~. PERMIT: ~.:. :: ~:e` :... .: r::..,, ...: .. ..
<br /> ~REQUIREMEN7 ~ ~ ~ ~:" ~~~~ ~~' ~ ~ '
<br />:. ...
<br />
<br />~ ~~~ ~
<br />
<br />~
<br />
<br />~ ~ ~~~~
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT~.~
<br />... .. ; ~: ~:; ~:.
<br />.: .. ;;
<br />
<br />,.
<br />~~
<br />~ .
<br /> .
<br />REQUIREMENT. ..: .. ~ ,.:.... ..
<br />•...:... ~... :.:
<br />~ ..
<br />. F ..
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNOFA PENALTY OF UW TNAT 1 HAVE PERSO
<br />AM fAMILIM WITN THE
<br />NFORMAT
<br />N SUB
<br />T
<br />D N Y ERAMINEO MD
<br />NA
<br />E
<br />I
<br />B
<br />O TELEPHONE DATE
<br />
<br />~•
<br />I'.Irha1"~1 :111((5 I
<br />O
<br />MI
<br />TE
<br />MY INQUIRY OF THOSE INOINDUAL9 IMMEDIATEL
<br />OBTAINING THE INFORMATION
<br />I BELIEVE THE SUBMI ~
<br />AE
<br />N
<br />;AND
<br />ASEO
<br />Y. $PONSIBLE FQR
<br />TTED INFORMATION IS 7
<br />
<br />')
<br /> ,
<br />TRUE
<br />ACCUMTE MD COMP
<br />ET T
<br />' ~
<br />^vironrre~tr /
<br />I ~lanan~r ,
<br />L
<br />E. I AM AWM
<br />SIGNIFICMT PEMKTIE9 FOR SUBMITTING FALSE INFO TMER[[
<br />E THA
<br />ME
<br />RMATON
<br />INCLCIDINO
<br />/ ~
<br />970) 870-271 _
<br />10 ~
<br />/ R
<br />9•.
<br /> ,
<br />THE POSSIBILITY OF RNE MO IMPRISONMENT. SEE IS U.S.C. 1 1001 MD 34 bIONATUIIE OF FNIINCMAL EXECUTNE
<br /> U.S.C. ! 791 e. /AvWOYJ I.r,SM VIIM JbNhJ 1„rY ~/M7F luMr W b 710,000
<br />TYPED OR PRINTED WarmuMun i,w•iavnrllWMfrwn emoneM rM 6Yrn.1 OFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV
<br />L:VMMCNIS ANV CAYLANAIIVN Vh ANY VIVLA (IONS /Re/elenCe a//dMMmInlJ hltel
<br />,LIIL~tiLL~ S~L1.,S ~iNll ~IAIVEU FL;k 1JYite24hK PrttLl' Lv~.vT-SLl i.,,.17 F1 Iar EL;.- :.~~.uI~LMLr.fS. L1IL v
<br />v Kl_/a ~t bKAt; SAr~~r L,_ A::,;LYSIS h[. Vii1KLJ I~ YISIeLt SrICLr. IS L~,cr VE U. .. ~'TKLY `.AMr'L iNv 1r;~TRtL.llurv S-I .L.. vF
<br />iV 1. <.
<br />EPA Form 3320-1 108-961 Previous editions mey be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) UU J ! 4 / y 61 U U 1- 131 1 PAGE lOF
<br />
|