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PERMIREE NAMEIA~nRESS lluduh
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<br />CC 4UCL9 h.INE `.~.'
<br />ADDNFSS CGU_.Y RCAD AA ' ~___. "i :.. -.•~._
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<br />LOCATION ~.`z -_~_
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<br />PERMR NUMBER '_~ -~~ DISCHARGE NUMBER
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<br />v ~ - ~? MONITORING PERIOD
<br />'~-FROM YEAR MO DAV ;TO YEAR I MO DAV.I
<br />O ~~ %7f}j/1= /11-J3/ I1J-1Jl i :'~ r/76In /IF-7-l /J0.311
<br />~~ 34T APPrOYed.
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<br />STORIYATER DZSC HA RGE oval eJpreJBDPDI
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<br />NOTE: Reed Instrucllons before completing this lorm.
<br /> (3 Card Onryl QUANTITY OR LOADING _.
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<br />~ ll CUrd OnlvJ„ - pUALITY OR CONCENTRATION
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<br />NO. FREOVENCv
<br />SAMPLE
<br />PARAMETE0.~ a ' ~ f31-611 -
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<br />I !5.61/ '• EX ~ OF TYPE
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<br />~. AVERAGE'` -
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<br />_MINIMUM'
<br />AVERAGE
<br />MAXIMUM ~
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<br />l63-63 ANALYSIS
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<br />Uc!IT GROSS VALUE
<br />FFL REOUIREMrEJ1T~ .•.:~:,.•.,_"--.v:~. r.-''4'c,'; 00{={:? ; ~I~I`FUr R `; ~` ~MAEIt7U~1 SU 3 = 1~0~7TH
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<br />;HAU THEAYt1fiHT fLP.!iT MEASUREMENT: - ¢ QO lj L•1/7
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<br />~FFLUFfiT GrlOSS YALIfE REOUIREMENt~ ;l.30~UA•AY~ 0~ t• NX: _
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<br />;F'FL1IF:NT CROSS VA U% F~OUIREMENT
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<br />.,LL AND:.rREASE - 3.sAMPLE :. ~ a~:*a~ta _ '= r f - >/ati'~{IiY; ; O'40a4a _
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<br />cfFLUi'NT CROSS YRLL'f. 'REGUIgEM~ENr.~ .~
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<br />... REOUIREMEt1T.
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<br />NAMEFTITLE PRINCIPAL E%ECUTIVE OFFICER •% CERTI
<br />.I FY UNDEP PENALTY OF LAW THAT I HAVE
<br />P EPSONALLY EXAMINED 1` _? ~ 'r pr
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<br />/= T TELEPHONE DAT E
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<br />~ - ~ AND AM FAMILIAP WITH THE INFORMATION SUBMITT ED HEREIN; AND BASED -
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<br />" ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIAT
<br />OBTAINING THE INFORMATION. 1 BELIEVE THE SUB ELY RESPONSIBLE FOR
<br />MfTTED INFORMATION'
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<br />;A IS TRUE, ACCURATE'ANO COMPLETE. I AM AWARE TMAT THERE ARE SIG . :
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<br />;•~~7E!{?!"~ ~ ~ - ~'
<br />-• NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING _ i '~ ~ `'
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<br />' THE POSSIBILITY OF FINE AND IMPRISONMENT.;SEE 1B U.S.C. t 1001 AND ~ SIGNATURE OF PRINCIPAL ECUTIVE f 'J' "I A
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<br />-" •TYPED Of(PRIIJ EIY ~ 33 U.S.C. 1~ 1J1D. /PrwfNa uMrr (Arse rrarura mrJ Nrhtlr /ina uP ro JI0.000
<br />rMormmlinu=Il lmpwonmrnr oJl/rrvnnl monr/uaM llevn.l
<br />OFFICER OR AUTHORIZED AGENT
<br />I
<br />NUMBER ~~
<br />YEAR
<br />MO
<br />DAY
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (RtjermaPllaffarhmtnuhnrJ ~ - I
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<br />SF NO'•'DI:/CHARGE OCCU::S REPORT' °NO..DISCYARC:E^. CIL At7D CF.EA9E~ .,EE FOQTNO~E,rP/. C--f1USI nF.~CTkCf _TF ~j(tCY-
<br />'.'L:7!i5 CLAIN~O. I'SS-=t!UST DE REPORTED AT ALL TINES. '~
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<br />EPA FOTm 9320.1(RBY.g•88)PFBY/GUS edifIOJIS meFDB USed. ~ (REPLACES EPA FORM TJO WHICH MAY NOTBE USED.) ~. pAGE OF
<br />001~3/900n20-1u02 1 I
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