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PERMIT NUMBER ^ " I I + DISCHARGE NUMBER , . ~ _, I <br />r <br />"MONITORING PERIOD <br />FNOM YEAR MO DAY -TU YEAR MO DAY <br />I MINOR (S08R YC) tlRTRS <br />(xim ns.zJl.. nd-u . ~ ~. n~rn ns~m clam :, NOTE: Read Instructions belore comDlatinp thlg lorm. <br />.._... _ <br />~ <br />~ <br />~ <br />•~ ~ <br />~ , <br />i /)Card Only/ ~ QUANTITY OR LOADING .. .I. .. <br />~ - /i CaNOnlyl QUALITY OR CONCENTRATION <br />' ~ <br />NO <br />FREOUENCr <br />SAMPLE <br />PARAMETER <br />' .- ___ <br />~ <br />_ _. ___ ~ <br />~ •~_ <br />•I 1 <br />~a (i~Jll !JI-61/ pg.iJ1 1i6J31 /]6611 . <br />EX OF TYPE <br />1i7-J7l <br />~ 0 AVERAGE MA%IMUM I UNITS ~ MINIMUM AVERAGE MA%IMUM UNITS ' (glfiJ A/~L~iS i6g Cp <br />~ l <br />/F STATRE '48KR ACUI SAMPLE ~ <br />T :I!.~#~#OQ• OOIP#~'~I ;I:j ~#~#L`~ O ; <br /> MEASUREMEN <br />Gtl3e 1 0 0 ~ I ..fr PERMIT I. r•1 ~..~~~###. .#>P9#'+10 •, >Q#+'~ I .~ REPORT:s :'.u,4#?###;p '. REPORT ASS=O iHLY HA9 <br />FFLUENT GROSS VALO -,REOUIREMENT~.a ;~.._g;..;:r...-j <br />•. .. 9 #~3~'~ •'SINGSANP •~~' <br />. ''SINGSANP PAIL= I <br />F STATRE 96KR ,ACUj <br />r <br />~1E~HALE3 PROtlELAS~ '.. 6AMPLE 1 <br />MEASUREMENT i <br />r ##OIP',~~: <br />II <br />;~ti!.q_ 1 <br />~ O##L14#i I.~:. <br /> <br />.._._.~ F,i.•: <br />•!, r:,i~ 1., .1 ~`~~'X~~ <br /> <br />:..,-.,, . _. ._y' ,y,!: <br /> <br />Q ., <br /> <br />_ i ; <br /> <br />t <br />A.,N6C.'• 1 0 U .. ~ ~,:••PERMm:•::: °._~'~~'~~ :( '######, #O# I .tiREPORT;:~ :c:g#~~~#:~ •,HEPOHT ASS=O '_''' <br />i TRLI' RAB <br />FFLUENT GROSS YALU REOUIRENENTT; L" =I"`7 '• - ,':• ; <br />. ~### I •- H N '~,"., '~'1, +;:i' ' I` - ` <br />~ I'i . <br />.,I <br />i`I '. '~r..:. ..'.~'.~.~ <br />.... .. ._ _. - ... SAMPI&~ t, <br />MEASUREMEN ..4' ,,fit f <br />.;:d„ :, .~ <br />~~I <br /> <br />, <br />I <br />- <br /> <br />:I ~ <br />_..._.. 1; ,~: :,~:. ,•,, L <br /> <br />1 <br />_ <br />, <br />~ I ~i. I:.. :. ~' { 1 <br /> <br />' <br /> r.h. PERMIT: ~ .,.7 :'• <br />rq ' ,^ ... <br />1T -V <br />. ,`+,.:L~ <br />': r~' .. }~-,. <br />- .. ' <br />~ I <br /> REOUIREMENT~ l <br />~ <br />'"R .Y•C..I +•J_., ,.y l~sn~':.~"'~• <br />Ti <br />i _ _,~ ^.,.. <br /> !•: SAMPLE ~ .. _ , ; .. ~ I I W <br />,. .' <br />-L. ___. ... -_ .. ~ MEASUREMENT_r .:~ ~~ ~ i ~~ ......_ r _. <br />~ I <br />~ _ PERMR :°I -{]:: ;~~:~ y.;l '_ I I :1J'icq:.-.1 ':' ~~.5 <br />~': ~ ;. <br /> <br />~ <br />REOUIREMENTj.A <br />;.rp .yy;+:. -.p.`':j <br />~'~'_' 'j'.({ <br />: <br />_ ". rT F.fe-. _'f <br />:i""'; I'Y'(iL~:.. <br />..i,,..'T .. <br />.. _ . <br /> ,.. <br />I "' SAMPLE" - I ' ~: ;; ~ <br />' I <br />~ <br />I <br />I • <br />I <br />;i <br />' .. <br /> <br />I <br />I <br />i <br />MEASUREMENT ~ .:'~:?' :. ~.. . <br />I _ _.. . ~ : <br />. <br />. _ <br />' I ,'. PERMIT" :.I <br />.1REOUIREMENTt. r`..t ~. 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Ir^- PERMIT:: r1~ <br /> <br />.REQUIREMENT r _y~~,;~a: ,? , .:~ <br /> <br />~ .u" <br />v <br />~ ow Lj <br />t <br />f <br />.a-i: ~ I '.-T'~tP. ~,•., ,~; ci 4• <br />,(. p <br />~ <br />.'' <br />.g <br />3ti?1'.'' <br />"l. ::i. ..' . <br />/f.~ ,~ <br />`Yt"~i.~' <br />ii' <br />~~'i , <br /> <br />r.r- .. <br /> <br />.. _ <br /> , s <br />.i <br />. <br />' ': y <br />t <br />_ p <br />, <br />d <br />S 1! <br />I <br />' <br />' ,' BAMPLE~ .. .1.,'~ .' ~ <br />` ~ <br />1 <br />~ ~ <br />~ ~, <br />I <br />~ <br />~ , <br />... .~ MEASUREMENT I ' <br />' <br />,. <br />~ ~ ~ ' <br />- ~ iaT PERMR.(.:y: <br />~ 'd'c ~ ` <br />~~~ ~ f ~, Y- . <br />:~r• .`~ .~I! a5 <br />~r'.:',J r, <br />a <br />" <br />'F, !I~' <br />' <br /> <br />~ <br />_ I <br /> <br />-AEOUIREMENT~' <br />Sid}-~ri'i ~. 6Y:.y.U..(.J <br />'.~ <br />..~1-...4•i.. = <br />~ ;;.~ •oF'"`..- ~ <br />y ' <br />:- <br />• <br />i <br />- - _. <br />NAMERITLE PRINCIPAL E%ECUTIVE OFFICER . I CERTI <br />AND AM FY UNDER PENALTY OF LAW THAT I NAVE P <br />FAMILIAR WITH THE INFORMATION SUBMITT ERSONALLY E <br />ED HEREIN <br />A %AMINED <br />ND BASED <br />~~ <br />' YELEPNONE OAT E <br />~ <br />-~7 <br />R CC II~'~: ~'i <br />: ~ <br />prl sri'~~ <br />I <br />~~ ; <br />ON MY'INOUIRY OF THOSE'INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />'OBTAINING THE INFORMATI <br />N <br />T ~ <br />• <br />~ <br />_ <br />: <br />. <br />µt t: V ~ <br />S , I S <br />r . I BELIEVE <br />O <br />HE 6UBMITTED INFORMATION <br />IS TRUEE,, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE S16~ <br />NIFICANT PENALTIES fOfl SUBMIRIND FALSE INFORMATION, INCLUDIND <br /> <br />6 <br />7y <br />5 <br />E <br />J <br />e THE POSSIBILITY OF;FINE AND IMPRISONMENT. SEE tg U.S.C. 1 1D01 AND :'BIGNATUREOF PRINCIPAL E% UTIVE as <br />0 <br />- o ~ <br /> <br />• -- TYPED OR PRINTED j 77 U.S.C. ~ ISIB. (PfnallYS undo Mrv narYlO may Indudt YP. b j10,mg <br />•ndarwolnrMn hnphonmrnrdbrrwen6manr.L tnd,Jylvn.l ~ <br />OFFICER OR AUTHORIZED AGENT - - <br />~ <br />NUMBER <br />TEAR <br />MO <br />OAT <br /> <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS/RrftrtnPe aOa!(echmtn(S Arn!1 "'' <br />SEE PART I.B. OP PERMIT FOR DETAILS OF TEST PROCEDURE.. REPORT RESULTS OF ITC TEST .AS `ItlININUN" AND SOX <br />tlORTA~.ITY.TEST AS °tlAXZNUtl°'AND„ATTACK ACOTB:TOZICITI TES?•HEPORT PORN TO DtlR.: COPIES OP ALL INFORtlATION <br />I.r <br />IDa <br />• 00003/900514-1715 FADE 1 OF I <br />