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r_i'~l;i-dlS k~~dse`.d1~#~~,xGcfl~ ; ;t' •' NATIONAL ~ : ,.tr r D: <br />Fxdi7 NanY/Lone.-"''//rmnrl ...:!~~ :n:~y~;, l,, .~ .-I ~ bli6 <br />ADDRESS ~L_ ~~Tl.ry~~~---~ .,..-.~1,=•~: Imo, G ~rG _ <br />1:• <br />--- F1 ~..~+S~TlE:---- ---I ~•;'' PJ(~L~ 'ti ~ n PERMITN MBE <br />{ -; <br />`r ., ~ .YEAR M <br />LOCATION--- ------ -~~-- ~~' 1 -- is FROM a ~ <br />~~ - r-,y r•-,r+, ri ne.n eT np dT - ~/7a7L /7I-91 <br />:I ILRE i i L It i•/' uatBr:cEhi/NPDES/ <br />JNI IlrfllmY 11CY1r111 (%1MK/ <br />P - , <br />I I <br />' "' ~: ~~ /' <br />~ ~50R!!,wA'T£R , '~?OIL Sk'. ,, G ..".T9°. <br />DISCHARGE NUMBER I: :~: ! 'I <br />" <br />' <br />- <br />- <br />~ <br />+ <br />~ . <br />~ <br />l I <br />NI <br />T <br />O <br />R <br />INGPERIOD !I! i ~ <br />ii r 'i <br />~ <br />~ ~ <br />~~ <br />DAV le YEAR MO pAY I! ~ ''{ ;: ~; ..i ; <br />.i,; _ <br />L, .r .: p I".7;IOP. a n: !. .. .;xTRS <br />tL7s1 ~ •=~ /Jr~ni /za-sa : nn,l, 9 NOTE: Read Inetruetloris belDre eomDletlnQ this tOlm. <br /> <br />~ (3 Card Only) -•~OUANTITV OR LOADING <br />" ~ <br />• <br />' <br />I /~CaM Onlyl, OUA ITY OR CONCENTRATION ~ <br />~ <br />'NO FREOUENCr <br />PARAMETER <br />~~ a lJtdl/ <br />p6JJ1 ;~ • <br />: <br />IJe~J1' /IbJJI :/J!-d// <br />I ~ . <br />: EX <br />OF SAMPLE <br />/J1.J) r <br />/ ~ <br />AVERAGE ~ <br />' MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE ; <br />MAXIMUM <br />UNITS <br />A%~LY <br />815 TYPE <br /> , , 1E363 ~ /ACID <br />k'll SAMPL6 ~ <br />MEASUREMENT '##+}>fl},lti <br />..i ,I~ 4tlr;1~#:` <br />' 1 ~ ~ T <br />/J <br />~ ;rat,:rs#~sF ~~ ~ <br />~ <br />,~ ~~ <br />~ ', I <br />/ <br />_ <br /> <br />~ ` !. - J <br />- <br />/K - I . <br />~Q <br />' I: LO 6R p <br />~L <br />:~ ~- <br />~.:Ul. /j ~ Il n PFRYIT.-~0. ~~yyy~, ..,,~~(( <br />.5 ~'NM##r~r,V.-'' <br />'~ .I. .~yy <br />r.~~.q ~,ry ~' ~.I :.: ,. ~• I IY II ~ <br />J ~: _ I:L_ y <br />w~i~ l <br /> <br />=FCT P. I: X19 : <br />VA UE 'REQUIREMENT <br />~° .-~ rd's " <br />~ <br />.../ r" .trt <br />„1 s <br />?f'C li. .,v <br />`M1i:¢ <br />•T~~ ! <br />.f•`. li _ <br />~ <br />1 } <br />- <br />7 <br />I <br />. <br />) . _ ~ S : <br />:.,OLIDS, lOTP.L SAMPLE M1~ <br />MEABUAEMENT-. .Za,~=#r#it ~ #fi:irl,trq t:}r:ir::.:` y, ~ ~ <br />6 , ;j . ' <br />U S Y P.I: C c D - _. r1~. ~_ _ _ _ U ., ~8. QO I I d <br />::U5iG 1 O D ^ PERMITrY.. <br />~'REOUIREMENT~ .:_'~(T1#.Y)101,'„ <br />V <br />';"3' ^IQLXt17r%O# <br />'il: LZ•. ;, <br />r <br />: ~Sr'% =AYtG ~~ <br />~' "O.A?ll.:•F" <br />C . <br />T j5~''~, 'l. <br />I •I ~lyCW"~-II ;~, <br />y <br />,, <br />~ f til.'L/F. <br />( n`AB <br /> <br />I \ Q •' •1' , <br />~. ~ d . <br />1'. m .F~ ,~., , <br />r <br />. <br />' nom: <br />r~ <br />t1~i•4 r <br />- , <br /> <br />~ <br />w . <br />1 , , <br />I <br />.:JUGS 5ETT1°AHL£ <br />A ~ .SAMPLE. 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COHD•JIT OR SAMPLE r._ '- L. I <br />' _ ~' <br />~ K1=ji:#eh1 i.}LN{r#ir{r #i,!szsz#. <br />) <br />.HP,IJ YREAIPENT FLAH7 MEABUREMENTr 'O,5 <br />yS:" 0.763 I :. - ,,n <br />. /,O~ <br />.,0 1 -Q ;.O ~ PERMIT'. <br />REOUIREM~IIT'~ POAT, ..~ <br />I` ~~ <br />F^ i M1 'w, <br />,.k,REP9R2- '' r4~4# # It <br />-.r ;? a IA#1YQ ~` 1(A:;' <br /> <br />t <br />' <br />' r~ '#Llt'/I~ ¢-_" <br />4. '.^•{cQ .L: <br />~ _ <br />EEKLY <br />• 1~ <br />NS; A. <br />~ ^NT .9rti~ t L _ ,v ,. ,, r:' ~~.' - <br />, I. :-4. i' <br />' !1' 1 '1 -'{+'..S r{•;4 ie- - '~' <br />`.OLIDS TOTAL - SAMPLE' ,: <br />:' ~.?rt#9rA#:f <br />. ~ Q#'vrfR~R r Ct:.•' ;t. r•. xn <br />/ <br />pI550LYF.D: -~ - MEASUREMENT <br />. ~ ], •., j, ;} ~ I ~~. ,~, <br />70295: ' n b . 0 .. A~ PERMIT <br />'~ '~Ip>b#3~0/4,', ~-(-d0!yL~~4!b~ i:a# #qp#¢#~% <br />~ <br />` .yctglo~aa,;.. ~-' aEPOaT~.: <br />~ i ~ < <br />• TREY RAD <br />} 1 F UT R. . r REOUIREMENT w'+~c' `k yl ° "M~l•Y 1: ~ i sc~~,~ - ~'. r, :~. ' .r•I <br />•J•~ '«: ti .I I 11 K^ a <br />'1 - r. <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I CERTI <br />AND AM FY UNDER PENALTY OF LAW THAT 1 HAVE P <br />FAMILIAR WITH THE INFORMATION SUBMITTE ERSONALLY E <br />D HEREIN; AN %AMINED <br />D BARED _ <br />" - ' ' TELEPHONE ~ DATE <br />""~~ ~ <br />, <br />~ <br />~Qe <br />t ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR ~ - "' - I •i <br />'~ <br />I <br />'~~ <br />dh <br />Dr <br />JlV I1 <br />~ <br />~ _ QBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION 7 <br />~ ~ <br />~ ~. <br />r' <br />~ ~ <br />-_ ~~ _ IS TpUE. ACCURATE AND COMPLETE. I AM AWARE THAT TNERE ARE SIG ~ ` ' <br />~~ <br />II <br />t, '~Y 1f 1 `~ ~ E - NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br />THE POSSIBILITY OF FINE AND IMPRIBONLIENT. SEE 18 U.B.C. 1 1W1 ANO SIGNATURE OF PRINCI AL EXECUTIVP <br />, ) • ~ ' I' !" <br />7 ~® S <br /> 33 US.C. ~.t 1318. lPrnolrb wder rAU• errors arrr Indudr fig uP ro jf4ooo , <br />TYPED OR PRINTED rMa,wMrw Mpironlnrnr o/Wrrrrnlrr~w,.bdnd Jlevm.l OFFICER OR AUTHORIZED AGENT j i EA I, NUMBER YEAR Mo DAY <br />UIL A1GD G8EA5E; 56'E FrgT!IOTE 'Fl.j~ O;-HOIIST Iii?DRT If EXEt1YlI095 CLAIy,ED. TSSr`10$;~ IRE' }tEPJR'fEU AT ALL <br />~IGFS. " II ~ I, I. I <br />edltlons <br />00031/100'5139-17yu <br />PAGE <br />of <br />T '~ <br />