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MT WT L'C /1.161 /17./9/ MT,v,D ._~ <br />_ooREfn_PI2NJL_CS~.E---------R_` .._....., I,Ir ~~,V•~V0004. <br />~SUbH N4~M oMg <br />~ <br />_--~~~~'~~~(~~l ~~~~~~- •IRMITNUM[EI[. olFCxwncaxxr[[R <br />~•~s 'Ires6-30-91. <br />ex <br />F- F I ti A .PP P <br />----OA.ti~RF.F-K-------~~~~'- - MONITORING PERIOD SU&FACE F;U'NOFF THCUT CRY, <br />•_weruTT <br />. . <br />________________ <br />.OCATION FROM YEAR MO DAY Y[AR MO DAY <br />_ -------- <br />_ <br />0 ro ~~ <br />RTirt <br />dAtl Nu D1SCh!AHG <br /> --- <br />----- <br />. 110.1!/ l1F731 !1*- Sl_ ~ ,{16- 1 118.1 1 ! 1 E I_ <br />NOTE: Rsad inftruetlonf ba}ore eomp~atinp thif form. <br /> (J Card Only) QUANTITY OR~LOADINO <br />~ (1 Card Only) OU ALITY OR CONCENTRATION FR EOUENCr <br />SAMPLE <br />PARAMETER (16.13) (llbl) ,- (da-17) (16J3) (~IQI) NO. OF TYPE <br />(i1J7) AVERAGE' - <br />-MA%IMUM~r UNITS' _ - <br />-MINIMUM AVERAGE MA%IMUM UNITE E% <br />63fiA wNwvfls <br />(61da) (6970) <br />OIL AND GREASE SAMPLE it+$b01k - ( goy - - cAY>s~a 4+a4T~a as#41P <br />VISUAL MEASUREMENT _ <br />6u066 1 O 0 ~~rc~n}rEF"~ ~>~~a .~~ ", < ~~~. <br />>3 <br />~ <br />YL'S=1 sW" ~~ a <br />~ ` ~~ ~-~ <br />r3~F$ <br />~P <br />` ~`°~ xs <br />~ <br />~3.I~Ig~~ <br />4r•ar. <~~ <br />~ <br />~~~& <br />,'~~~ <br /> EQt/i~f#[M BMA ~~.~~a ~~.~:~~ a <br />~ s <br />~~° ~ <br />~, <br />~ , <br />~~ s <br />~ .~ <br /> ~ ~ ~ <br /> SAM PLE - . . . <br /> MEASUREM[NT <br />I_ _ <br /> •R~~ECU <br />Et~ ~ <br />- <br />B' <br />g ~.~ ~, 9 I ~. ~~~~~' A °~ ~a~~3~~s <br />i'~ :w <br />~~" <br />~ <br />~ <br />~~ <br />' ~ ~~x x <br />~ <br />'~ ~ <br />~~g <br />~ <br /> ~ <br />S~LM <br />" <br />t` <br />~ > <br />~ <br />~$; <br />~A <br />g~ <br />. <br />x ~ ~ <br />« ~ <br />>~ <br />o- i, <br />~ <br />. <br />~~3 <br />3~~ <br />~ <br />' ~. <br />- <br />ii p ~ <br />; <br />~' <br />. <br />~ <br />a <br /> ~ <br />g <br />e. ffi <br />. p <br />> <br />a.g ~ . <br />. ~ r, - r~ .~§&''_ ~S ~«K'$~ <br />~ 66F ; ~g~ <br />~ <br />~q~ <br /> BAMPL[ - _ ^ <br /> MEASUREMENT <br />_ ~ ~ <br />_ ~ <br />,./ ~ ' <br /> <br />.. x:g~ E~1 [ ~" <br />8" ~. <br />1tC <br />U <br />RC <br />~ ~~p!~>A'. >~ 3 <br />~ X <br />~ ~' <br />'S $,¢'M° <br />m1" ~ <br />~ ~4 .~ell~~ <br />~ <br />$ ~ t ~f <br />• ~~x ~ <br />@ffi ~ ~.'S ~~~ <br />.~,I~F ~ _,} <br />~ <br />Z <br />¢ <br />g g~~ <br />~yP' .°o-Ye`y .a <br />~^~`p~' <br />~'$ <br /> I <br />~M <br />Q <br />~ ~ <br />~ <br />~ <br />e~ ~ ~iz'e ~ ., ' b8 ~ . <br />~ a ~~ ~ <br />`¢ ~~+ ~ &~~ ~~}x,~~ <br />, ~~~"^tw' ~ <br />g <br />~ <br />b I'F" %A. "g~h ~ <br />~Fa ®' ~ ate: <br />'• SAMPLE - <br />~ ~ ' <br />'y <br />,. MEASUREMENT _ ~ - <br />~ ~ - <br />~ ... _ ~'LLINM~7''~~ <br />REE <br />I <br />C <br />ENT <br />U ~.~ ~~~~'a ~~ £ <br />~ ~~~ .. 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D~$Y ~,~ <br />~(~ <br />'a a- ~'~ Y~~~a ~~ >3 <br />Y s <br />> <br />~ <br />~ «`~~ <br />~ o- a«~~S <br />,~, ~'.m g.~'a g:a,' <br />~~ <br /> E~UiltcAt <br />iY <br />w <br />~ z g <br />~ <br />z~- <br />m ~' <br />. <br />: <br />~ <br />.~ <br /><r ~. <br />~` <br />~ '~ <br />- <br />- q <br />~, <br />~~ c~sm <br />'~ ~.~ <br />, <br />~~. <br />. ~ <br />~~a <br />a~ <br />~ g ~ <br />~~%' .~. <br />~~., <br />~, <br />~ <br />. <br /> ~ <br />~ <br />~S . <br />~ <br />m x a~ <br />> <br />a g <br />. ~. <br />~ <br />~: s~m <br />s; <br />;. a_. . <br />,. <br />g <br />' •AMPLE ~ ~ - " <br />,_ - MEASUREMENT _ <br /> e%~Pp R'I <br />REgUiRR [.IT~~ ~ <br />E <br />tNT n"a o'~%~".era's '$.~ <br />~ ~~ <br />~ £d ,,~ <br />s <br />~ <br />' ~ "~"$`~~r <br />~ ~~y rY~~ ;. <br />` ' <br />~ °°:~'#. &;~''~ ~'~• <br />~~ <br />~ 'i`l ~,~ ~,g ~ %y ~.,., <br />~ <br />~ <br />' -'".:.s. .'°~ ~~', <br />~ ",~~°.e..~~i <br /> ~ <br />_ ~ <br />~ Hv <br />~~ <br />:~ «~ `4 <br />•~:'~ <br />~, .~d <br />: <br />?~ i~,~'.. ;y <br />~~.~ <br />~:~ <br />;8'~'"~~+. $"a a ~'a" <br />~ ~;~ ~'~~~ <br />NAM [/TITLE PRINOIPAL [%ECUTIV! OFPICCR I CERRFY UNDER PENALTY OF LAw THAT, 1 NAY[ PERSOxALIY [%AMIN[D <br />wND AM FAMILIAR WITH TH[ INFORMATON .SUBMITT[O NER[IN: AND'BASCD ~ ~ .TELEPHONE D A T E <br />l 1 <br />-, F L!)'~C, OH MY INOVIRY Of THOSE INOIVIp1ALB IMM[DIATELY'R[SRONSIBLE ~'FCq <br />OHTAINIHG THE INFORMAT10:1 1 ~BEUEVE~ THE $DBMITT[D INFORMATION <br /> <br />~~ - - <br />K IS TPUL ACCUPATE AND COMRCTE I AM AWARE TNI1T TNEgC Al1E SIG <br />NIfICANT PENALTIES FOR $UBnDTING FALSER INFORMATON <br />INCLUDING .~ <br /> <br />M,N <br />S ~- <br />- V <br />, <br />TN[ POSSISM1rtY OF FME AND MPRI$ONMENP SE[~IS USC f 1001-AND <br />_ <br />3~ 1 <br />~~~11 <br />~3 <br />~~ <br /> <br />-''1 <br /> nusc f IT9 rPrnanr. IIMr. rAr~ nRluln nFV Mrldr /mr. YR I•. tl4MA. SIONATU RE OF PRINCIPAL'E%EC UTIVE b I <br />TYPED OR PRINTED a.W ~.•naalmlun lw10~x•~^I.Irr a/A.IUwn6n.~nlA. and .f ,~n.F.r OFFICER OR AUTHORIZED AGENT A A NUMBER YEAR MO DAY <br />TS5 E TCTAL ikCt+ LI"II'i5 7i: LL BE NAIVED, AND SETTLEAELE SOLIDS LI"1T AE`YLIED h'Oh <=1QYk,<ui{ri PHtCIF EVENT- <br />5EE I.A.2, FG IV, FOn kEi~UIi1EMENTS. :RTHLY SAMPLING INSTFUCTIONS-I.C.9, FG XIII. <br />.PAFrorrp~320.1 (RSV.4f1B) OrBMousBditionamaybBUaed. (RLPLwccf L-w PoRM r-1e wHILH Mwr NoT fL ufcD.l PAGL oP <br />