Laserfiche WebLink
PERMIT EE NAME/HUI~NCJJ uw mu. <br />FiNlily N.me/I ar~lion f( di/Iemnll <br />NAME_ ~P.A+r'AL~AL-L~..'a~SC'.-~F.---i ~L--YI~L_-- <br />ADORE88~vn]_$IlI1j$f~[ O___________ <br />FACILRY ________ <br />.--_ __ <br />LOCATK)N ~L 17~ pl{J t~ 4F <br />-T _ _ ~_______ <br />•TTO• A D•J VCTF\CRT <br />DISCHARGE MONITORING REPORT I I1MH1 <br />I ?-Ih) l 17-191 <br />r. n'T: 17 (~. <br />PERMIT NUMBER olacnA..a wursa. <br />MONITORING PERIOD <br />YEAR MO DAT YEAR MO DAT <br />FROM ~ TO <br />. an.m rnnl .Te-x1 r>a.nl nn-o.l n2ln <br />AIM ~q <br />(S!I 1) R 9 W) fgrl~~proved. <br />° - P I N A 1. OMB No. 2040-0004 <br />~"4T1? W..°.T l~?r4~CM;PIEF~W-~TQ'~1 <br />YNOTE: Read Instructions belor' omDletlnB this form. <br /> (l CHTd Only) QUANTITY OR LOADING (4 CeTd Only'1 QUALITY OR CONCENTRATION <br />PARAMETER (46-S.i) 154-b1) (J8-451 (16-SJ) (51611 NO. FREQUENCY SAMPLE <br /> EX ANALrys TYPE <br />( 11-77) <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNIT9 (6311) (41dr1 16V-101 <br />LSD STATRP, U9HR ~.~ SAMPLE ~i~#.~`-r .''.L`Y'.''-ih 'vr«y.`• ."I.~iG:=: ( 7~) <br />~ERL~DApHN.LA MEASUREMENT <br />TA~3J 1 D ~ PERMIT ~^~~+~¢¢ ~~~~~$ `~% R?PORT 3##+k4x ##$:~¢Ayl ~R- iRi:! 9A~ <br />EPPLOP.NT ~R~SS 4AL0; RE°UIREMENr. rC.`t `I1N V IP f x'77 <br /> SAMPLE <br /> MEASUREMENT <br /> .PERMIT <br /> REQUIREMENT <br /> 9AMPLE <br /> MEASUREMENT <br /> PHRMIT ~ ' <br /> REQUIREMENT <br /> 'SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> li[QUU7EMENT ~ ~ .. <br /> SAMPLE <br /> MEASUREMENT <br />' PERMIT ~ .. <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> 17HQUIREMHNT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> IiEOUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE 01=FILER 1 CERTIFY urvDER PENALTY DF LAw THAT 1 HAVE PERSONALLY EgwMINED <br />' <br />1 TELEPHONE DAT E <br />:C <br />N A'V ~~~~~ / <br />K N.ID qM FMIRIIR WRH TE YFORMATL <br />~N SUBAITTED HEREIN. AND OA.SED <br />ON MY INOURY OF THOSE NOVDUALS MMEOMTELY RE~MN~ LE FOR <br />• OBTgINWG THE NFORMATaJN 1 BELIEVE THE SUBMITTED INFORA4TION 15 <br />I <br /> TRUE ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE L r <br /> SIGNFICANT PENALTIES FOR SUBMRTIND FALSE INFORMAl10N INCLUdNG ~~ \ <br /> , 65~ ~ <br />l rHE Po551BLrrr of FNE AND MPRISONMErvi <br />SEE IB uSC <br />/ 1001 wND 370 LL J <br /> VQ ( . <br />. <br />33 USC f 1319 (R:nanin under Ihae nnmu m <br />induJe lion u <br />m 91GNATUREOFP INGIPALEXECUTIVE <br /> q <br />p <br />1 RE'.' <br /> TYPED PRINTED flO1 <br />W aM w maaimur.. imprYOnn1MI n( bn.xn b monlAs and J yranl OFFICER OR UTNORIZED AGENT NUMBER YEAR MO DAY <br />COMMENT AND EXPLANATION OF ANT VIOLATgN9 (XCllltnC[ III IrrlCRminIS IllRl ' <br />SEE PAR! I.R.S POR D?TILLS 7P TEST °R~C'•n!14P.. RP.P~BT LO4f.ST DLL7Ti79 (a RP'LORq'C) J!!I~9 LS LF.TIIM1L T~ <br />59, 7P TF~ ~R_9NISt1; (L.S^) At70 AT?ACa A^.BT° T:ttI~Ti T`.ST 3.:°7RT PO'th rT 9'I R. C7?[4..i O? A j <br />(REPLACES EPA FORA~O WHICH MAY NOT BE USED.1 ~ ~ - ~ ~ ~ n <br />~ OF <br />