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I`[RMITTEE NAME/ADOR[!! /1n[IudT <br />!'unliry A'ame/Locarbn rent/ ~• Ic <br />---FJ.~ii1'3FF ------~~25r~L- <br />------- <br />rncrurY ______ <br />LOCATION <br />bil'G: L!i'kiS [.. PiT40.°.'ISDN PA RSlDENP <br />N .T TIONnL POlLV T11MT BISCNRRGC CIININATION STSTCM INYDl SI <br />DISCHARG NITORING REPORT /D.URI <br /> Il6 !7 /9 <br /> I , '. 1 <br /> PERMIT NUMBER DISCNARCC NU.IFu <br /> MONITORING PERIOD <br /> YEAR MO OAY YEAR MO OAY <br />FROM r jl TO I <br /> 110~1l1 /11171 /1115/ l16~17/ 1:8:91 lJ0~Jl1 <br />'1 [ ?` I) R Form Appro <br />(ill '', Ir. ti ;(~ I>'Offl~[U o. 20 - 004 <br />F - °L'IM1L Ezpires 9-30-91 <br />I i I a r /(! 1 "~ !' C T !) i ~ I :' / P I C a (' D^ L Y <br />rNOTE: Read instructions beforl completing this form. <br />i (1 Card Only) GNANTITY OR LOADING 14 Card Only) OUA LITY OR CONCENTRATION <br /> <br />PARAMETER <br />(16-31) (7461) <br />(19-4J) (46-J1I (7461) <br />NO. Fw EOU ENC• <br />OF <br />SAMPLE <br />TYPE <br />(3117) E% Lr315 <br />NA <br /> AVERAGE MA%IM UM UNIT6 MINIMUM AVERAGE MAXIMUM UNITS 67671 1646X1 169481 <br />i~:l <br />6AMPlE .'~:Y::-. .-'.`•4'-`. ( ~ <br />~ .. .-, <br />I <br />I- <br />~ ( ice) <br />` I <br />/ <br />~j <br />~ <br /> <br />MEASUREMENT <br />~r <br />] Z y <br />~/ <br />/ <br />/ <br />® <br />)!~ ~ <br />J <br />~~"`~ <br />I, ~rI I'D L ). D .'."PERMIT. ~. <br />' a:.'M#Y V${[~~ <br />~' <br />'' ..l: ~•!r`L4 ~'i ~ <br />~. <br />. 'r='r'T ~ Jfww;a:~1Lrt 0 <br />'rFLUP <br />i <br />NT ~AD~S YeLll pEOUIREM ENT <br />. " <br />~ . <br />..: .. ....... <br />. <br />. <br />. , <br />.. . ' <br />F <br />[ 6AMPLE ( <br />[~~ v~~f~ •+~ ~r . . . .-. ( ~ <br /> <br />F <br />7 1RU <br />TFF. T;1 F~7T <br />PLON <br />MEASUREMENT O. VIp O. 061 O ~ /D f'NJI/yy <br />J'.J ~IJ:J 1 I 0 ',.~~PERHii•:;. <br />' •:~'R21?OHR;; <br />. <br />. <br />" <br />' OPTION d'L~- <br />, °~#;X ~~r~.'.,J'.. <br />~ <br />' ~; ~~X,YiL ~~rY~ <br />'~ .: :~rs,;r,;:;:Y <br /> <br />~. ,;:>;: <br /> <br /> <br />-'- <br />' NrE . <br />F'?FIUL:NT GP <br />DSS VII T <br />rI! REOUIREM HNT. <br />' <br />: <br />° . <br />.. <br />: : <br />36 <br />-" .. <br />~ A . <br />...;.. .. ;: : <br />.:. , <br />' <br />. <br />, <br />. :.: <br />:. .. . <br />(fA Y . <br />- <br />.^~ <br />B T <br />!'ICE ANC ~?F0.5C SAMPLE vv .. ,i-i ( 94) <br />. •. ''-~-;fi";-+'` <br />Y, .. <br />( ) <br /> <br />4ISl!/1L MEA6UREMENT <br />~ <br />~ <br />~ 3a <br />Ulsv,4 <br />E' JptO I Z ~ PERMIT:, % y i <br />.."I;EIrY Y.iF`'.. <br /> <br />~ <br />'°' <br />: ^.. ~ <br /> <br /> <br /> <br />..: <br />,i <br />' <br />' ~ <br /> <br />ES 1 ./~ <br />YYY~~Y~ ~iYV J~T A:~-i~~AJ~ <br /> <br />4CB/ <br /> <br />ISU9L <br />~.r <br />q <br />!r~LU~NT GRO"~ VPi REOUIREM ENT :% <br />: ~~ <br />• ' <br />i ST <br />.. <br />r <br />No=G <br />wn• <br /> SAMPLE <br /> MEASUREMENT <br /> ..PERMIT ...: • ~:. <br />... .; .. <br />.. .. <br />~ ~~ ~ <br /> <br />REOUIREM ENT <br />•' ~ ~~ ~ . <br />""' <br />~ <br />' <br /> 9AMPLE <br /> MEASUREMENT <br /> ~" ~~PERMIT.' ~~ ~' <br /> RHOUIREM HNT ` •- ~ ' <br /> <br /> 6AMPLE <br /> MEASUREMENT <br /> <br /> REQUIREMENT ~ , <br /> HAMPLE <br /> MEASUREMENT <br /> "PERMIT.: <br />... '~ ...a :' ::' <br /> ~ <br />NAME/TITLE PRINCIPAL E%[C UTIVE OFFICER I CCRTIFY <br />ugOER PFNALTr OF LAw THAT I HAV[ P[RSOHALly uAMwED <br />AND AM FAMILIAR WITH TNC rNFORMATION 6UBMITEO NCR[IN AND BASED TELEPHONE D A T E <br /> <br />A ~J 4 ~ <br />~ ON MY INOUIgV OF TNO$E IHpVIDUALS IMM[p1TELY R[SPONSIBLC FOw <br />OBTAINING TNC INFOwMAT10Y I BELIEVE THE S <br />BM <br />TT <br />N <br />T <br />j <br />1 I <br />ED I <br />U <br />FORMA <br />ION <br />IS TRUE ACCVRATC AND CONFECT[ I AM AWARE THAT TN[w[ AwF SIG <br />ld <br />L/ <br />~ <br /> HIFICLNT P[NAL LIES FOR SV EMITTING FALS[ MFORMATION INCL VOING . <br />. <br />/L.. <br />V QfVI E1/I(/\• I~ <br />l]o50CS11R]LI9r P <br />nd..IAPVSOaIUIrNTn <br />n Ifv <br />nrC <br />drll <br />'NU <br />ll <br />l~l <br />SIGNATU E OF PRINCIPAL E%ECUTIVE <br />~~. C <br />~~ /~ <br />3 <br />D~ <br />Zj <br /> <br />PED OR PRINTED I <br />a <br />l <br />nr <br />u <br />n. uV <br />% <br />ar.,l ~.rma.Ir•Il.r.lln,Vrl..,rrni.nrr.l N~Il. r.n firn~rnlA. and.+..e.rr <br />OFFICER OR AUTHORIZED AGENT <br />AREA <br />NUMBER <br />YEAR _ <br />MO . <br />DAY <br />~v~+ntN1 nnV cw rtAnw/IVn Vr AnT vIVLAIIVNy' .nf/flrnfr n1/ nIInI llminlf nlrll <br />C'.CL f, G1t:'~P.Sc__cp;E FOOTNOTE F/E PAG° 3. Q}'.TREY SP.17PLliJG III:;TRUCTIOtrS--PI)OT!IDTB ^/. <br />EPA Form X720-1 (RaY. 9-88) PAVlous editions maybe used. Iq EPLAC CS EFA roRM T-4B wHlcH MAr NoT .E usco I <br />FACE Dr <br />,T t1/., ... I._I .n T <br />