|
PFRMITTEE NAME/' CRESS 9rlJ. FrdlryNa./Locana. l/DIQ u,p
<br />NAME
<br />~. .. t.'. '.: 1: i. ,. ..: 1 :1 . ~ ,. ,
<br />ADDRESS ~-1/!..,,, 1;. .,,
<br />., .. ... (. J .1 ~., II L
<br />FACILITY
<br />LOCATION
<br />n I i'I.i'I .'i
<br />NATIONAL POLLUTAN' - ^CNMOE ELIMINATION SYSTEM /NPOESJ Form Ap- •ved.
<br />DISCHARC )NITORINO REPORT D~ _ OMB N, .. .40 0004
<br />IZ-16. 17-191 '( I' ; 'i ~' r "
<br />' ~: r ~ :11 r , c n ~,~ fi I ;• ~ ~ . , ~~ ~ ~ ~ Approval expires OS-31-BB
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />1 ~ !. 1. .
<br />MONITORING PERIOD ~' ~ :i'~: `'
<br />YEAR MO DAY YEAR MO DAY
<br />FROM .I 7 i'-i ', i TO ~ 7 : ~ 7 1 ':' " ' !' • ' ~' ~ `r .
<br />llasn raa-I31 r~r-451 r1~171 x19-Z91 x34311 ~ NOTE: IRnd In~tructlaubdori edmplstln0 this form.
<br />PARAMETER 13 Grd Ontyl QUANTITY OR LOADING !/Grd Onlyl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
<br /> N6531 1548r 138-x6 !/663 !5461/ OF
<br />l3I 771 E% 'W'uYNS TYPE
<br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS f3]-B]/ !54.581 l5.T70I
<br /> SAMPLE .. .. :: :: .:: ::: ::. r ' 1
<br /> MEASUREMENT '
<br />. . ,:..
<br />. PERMIT ::. r,: ~:~
<br />~ ;y::.;: y. ;:.. ', . ` f,.:; :: Q.',•:.` ~i . ~' 'a, 1 ~~
<br />.
<br />,
<br /> REQUIREMENT ~ .
<br />: ,..i .. I ~ ,. 1 1 s: r v I w ,,. ,
<br />_.: .., ..,.:1. SAMPLE .... ., ::: :.~:i ,;. ,; '
<br />
<br />`
<br />MEASUREMENT ~ ~
<br />'/
<br />,.::
<br />IL:. ..
<br />~' ~:: 'v ,: PERMIT :;::: o;: r,::} ~:: ~ :::. q:: ,::~ ~ .::: ;::.: r ,, ., . ~. 7 p....
<br />~ REQUIREMENT ~ ~ .. ~
<br />: ~ ~ ..
<br />,
<br />r :.: ... ;.
<br />:. :1:.. i 6 I, ~. sl ~
<br />:; ..;
<br />• • ! SAMPLE ~ '~
<br />~ '~
<br /> MEASUREMENT
<br />
<br />..~ ~~
<br />•v. _ i .. 1.. PERMIT
<br />:::.::: t..•::;. ~. .. ,:: :;~,g :j :i r, ~ 4:5r,.:~';~ r c ~'~ / rl :,:
<br />~
<br />~ I
<br />~' - ~ ~! REQUIREMENT ~ ..
<br />, ,; :
<br />. ::;, ~ t . v ~
<br />r•
<br />'• 1 .
<br />. ~ .. ..., .:: ~..,
<br />•~ SAMPLE ::::::':; ::::;: ;: t:;::; :~ :` ~: 1i :7 ::' ,1 . " , t. :;: ::: f 1 i
<br />_ . , .. , .~~,I MEASUREMENT
<br />c , _ _ ,. PERMIT .. , . . :, ,: .. ,:::. .. } r ,,•, :: ~ ~,
<br />:I,
<br />l REQUIREMENT ~ ~ ~ .
<br />. ~ .. ..,
<br />: _
<br />.I ~ ~
<br />~
<br />, .: ~(.. i. SAMPLE .:::. ,};. ... c' ,. -;.:i ~ 1 '1 )
<br />~ ~ MEASUREMENT
<br />tl ~ PERMIT: :;: t:;-:}.: ~: ~ :?:;:.;r„a' ~ 7b.'. r: ,G :1 r}~:),; ~S ~
<br />• '1
<br />:
<br />.,
<br />.'.r II. " t, r, 1.
<br />` ~REQUIREMENT~ ~ ~ ~ ~ ~ .ir:Y.. .. 7l' P , ~. / . 1
<br />;
<br />...,,
<br />. _... il: .. I. SAMPLE I ...{1
<br />~ )i,.', ,;. ;:: .'.: rr.
<br />„• , ,.., : •. , .• ,. _ •,,~ MEASUREMENT '
<br />' - ~ '- - '' PERMIT: ,I, .i _i:::Ai.. .. lGii "p
<br />~ ,.:,C,S:~ 0•: ?rr.. ...
<br />.
<br />.~: •,: REQUIREMENT .iULi?; .it~d: I.
<br />':l ..I :~;'~
<br />n
<br />~
<br />
<br />.... ~ ~
<br />
<br />,:
<br />...
<br />.
<br />. • •.
<br />. :.. I: ~., , . ~_~ : '. L SAMPLE ~.:;.:; :.;::;: :;:. ;::; :~ ;: :. :i ?, a.',: ~ Y .. ;;; , I
<br />'
<br />/ )
<br />i :~i L. MEASUREMENT
<br />, ;
<br />' " s PERMIT ::. •.: r,;: ,;::;:`~ ... .. ,;., :p t, t. ;l . r
<br />:; :; r
<br />03 i, i:: J i I
<br />.
<br />.
<br />.~
<br />~
<br />1
<br />`
<br />'
<br />REQUIREMENT
<br />..
<br />~ ,
<br />, s -
<br />~
<br />,
<br />~ :
<br />1
<br />! .~
<br />(
<br />.:.:, i :.~: ~::;
<br />~ l
<br />:. 1. a
<br />r „
<br />,,.
<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY uElDw PENALTr of
<br />AM FAMILIAR WITH THE INFO uw TNAT I NAVE PERSONAtfr ExAMINED AND
<br />RMATION SUBMITTED HEREIN; AND BASED ON / TELEPHONE DATE
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE fOR : % ' _
<br />~
<br />I
<br />J
<br /> OBTNNING THE INFORMATION, I BFLEVE THE SUBMITTED INFORMATION IS ! 1
<br />/ r. ,.'1; ~
<br />'
<br /> TRUE, ACCUMTE AND COMPLETE. 1 AM AWARE THAT THEAf ARE '
<br /> SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING
<br />,. I' ,; ~ 1 ,
<br />THE POSSIBILITY OF RNE AND IMPNSONMENT. SEE 1H U.S.C. f 1001 AND 33
<br />BIONATURE OF PIIINCIPAL EXECUTNE ,' .'. ' , (`; 1 . ~~'! I .J I i
<br /> D.S.O. F t7ts. 9Mr14A UVr Vww mnrt.. n,.r Y,W.d. IM. y ro 110,000 AREA
<br />TYPED OR PRINTED rMrmA.hxAn iRWAVnr.rWbmAwlsn:w,d,.W eYrral .OFFICER OR AUTHORIZED AGENT coDE NUMBER YEAR MO DAY
<br />V UMM[N 15 AMU [Ar'LAHA I I V N V f An T V I V LA I I V n3 1/re/BrenOe e// eRGCnmenrs oars!
<br />1. i'i... ., .. _.1 .. ... l.'..i:^ nr,'Ll:: ~.; .; !.LY .I: <= iJ-•2 :., :I•':i 1, fl ii f;.'ZE PYE\j :; ::Lr _, !,. l !.. ., c. ., '.1~
<br />- :, ... .. .. ..., !. ...T ... .IL:. „Ci, h6 nt'.~'L L'... .., rt. 1'.: r, '!'... :i „SJ5[C: yT c' _!; '. If :I. s
<br />_ , , ..
<br />EPA Form 3320-1 108-951 Previous editions may be used. IREPLACEB EPA FORM T-00 WHICH MAY NOT BE USED./ PAGE OF
<br />
|