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PERMITTEE NAME/0"RESS pndr6frWry NaWlncrron 1/D/Qfvw) <br />NAME '_,~I-.. ~ .- Ir. :. -.J?i l'9 '~ I .... . <br />ADDRESS `,I !, _ ,~) ~, ~ - <br />.~ .... f.:, 1. li :.; L 6 ri 1 <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLVTM• 'CNMOE ELIMINATION SY9TEM INPDESJ Form A~ •ed. <br />DISCHARG INITORINO REPORT (OMR1 M9 NL ~0-0004, <br />1-15i I7-191 :' (j L :. i. " ~ ~ ~ ~ ~ ~' Appiovel azpiree OS-31 ~98 <br />PERMIT NUMBER D19CHMGE NUMBER ~ ~ - <br />- =1'.,. <br />MONITORING PERIOD " 1 ~ E~'' <br />YEAR MO DAY YEAR MO DAY <br />FROM '17 t,7 +i.L TO 9T C9 ]^. :; ~i~ ~.~ ~~~.. r, i.~ I• .~:: :: <br />!10171 l11-131 171-161 !?6171 !IB-79/ !36311 ,' NOTE: Reed Inetructlone balors'eomlplatinp this form. <br />PARAMETER !3 Grd only! QUANTITY OR LOADING 10 Grd Onlyl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE <br /> !46531 1545/ l3B-051 /!653 (546/1 <br />E% OF <br />131-3A MALVSts TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS /6]-691 /50.5@/ 169-701 <br />.::, :. ,... _ ~ SAMPLE :;: r: ry:::;:.': i ~ :q) :~:~f :; ti: :; :: :: i~:::::. :: i I <br />~ <br /> MEASUREMENT ~~ '1 ` <br />" <br />. ,v:. .. <br />.,.. i V i~ ~ PERMIT ~. - n;: ~/ .. v <br />~ ~ .-1 ... :~;:~ :}:~G/-;; ~ ;li ... <br />... ~.~ <br />. <br />~ :. ~ ~ ,,, 1 REQUIREMENT ~ ~ , r cif ~ <br /> SAMPLE <br /> MEASUREMENT <br /> :. PERMIT-~ ~ ~ ~ ~ ~ ~ ' ~~ <br /> .REQUIREMENT ~ .. <br /> SAMPLE <br /> MEASUREMENT <br /> ..:PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ' .PERMIT . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ~~PERMIT .~. <br />:... <br />... <br /> REQUIREMENT ~ .. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> .PERMIT~~ ~ <br />~ <br />~ ~ ~ ~ ~ ~ ~~ <br /> REQUIREMENT ~ ~ .: <br />~. ~ ~~ <br />~ <br />~ ~~: ~~~ ~ ~ ... .:.~ ~ . <br />NAME/TFfLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENILLTY <br />OF <br />WITH T <br />NFD <br />M F <br />E lAW TNAT I HAVE PER90NALLY EXAMINED MD <br />MO OA9E0 ON <br />NMATION 9UBMITTFD NFREIN TELEPHONE DATE <br /> ; <br />AMIUM <br />H <br />I <br />A <br />MY INQUIRY OF TH09E IXDINDUAL9 IMMEDIATELY RE9PONSIeLE FOR 1"I <br /> O9TNNINO THE INfOI1MATON, 1 BEUEVE THE 6U9MITTED INFORMATION 19 ~ - <br />~ ;J (~ ~~(•L ---~ <br />t <br /> TRUE, ACCUMTE MD COMPLETE. I AM AWME TNAT THERE MF <br />O FK9F INF011MATON <br />INOLUDINO <br />11 <br />UBMITTI <br />P -I ~ <br />1 ~ <br />~ 1 7 <br />- <br />I <br />~ , <br />91tiNIROANT <br />ENNTIEe F0 <br />9 <br />N <br />~ ~ <br />~ <br />' <br />1 I <br />~ <br />~ <br />~ ~ <br />(•~ ( . ~ ~ iNE P0951BNiY OF RNE MD IMPW90NMENT. SEE 19 U.9.C. 1 1001 MD ]] PAI E]IE <br />TNE <br />610N <br />T <br />E OF PI / ! - <br /> u.s.c. 1 t ]te. lfwver. uw erAr mroro. ,e.y hn.W rr. w ro JI0,000 UR <br />IINCI <br />CU <br />A <br />~ AREA <br />TYPED OR PRINTED r.ermuYlwnYeWAmn.ntaanrMntmantA. rw6yrral +. OFFECER OR AUfNOR12ED A0ENT coDE NUMBER YEAR MO DAV <br />COMMENTS AND E%PLANATION OF ANY VIOLATIONS lRe7erence d/ sffscnments nerel <br />._..,...... .~'1-..- L.'I'.. nd.l. i!.~ '.i,.L': it C= l,l-1'?, i4-ii t. ?I'rCIF FVgk7 1C :Ldif1=G. !. ~'....... ~... ... , <br />-_ ...., ~.. L. [L. :+1LL !•tl: .. .+~PL.-:L iu d~..:trP::!; ..".rASURErFk95--SEE 7.L.Ir, .., - 1.,..;.1 ~_ <br />EPA orm 3320=1 108-961' PrevioEie'editioni rrtey be ' edd. ~ /REPLACES EPA FORM T40 WHICH MAY NOT BE USED.[ PAGE OF <br /> <br />