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PERMITTEE NAME/ SSp I.4 FmWry Na+/Ixenm (/Drpir+.:) <br />NAME <br />ADDRESS CIIi'~)~.j.1 ,;!F' <br />]1.i1 S`t'n"'; I;iCli'r:4{ l3 <br />r.'.'!:':1.; CD 1715x1 <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTAN 'HMOE ELIMINATION BYBTEM INPDESJ <br />DISCHAR ITORtNO REPORT (O Rl <br />1-le 17-I9 <br />r ,r.ntir, I~, PtP D <br />PERMIT NUMBER DISCNMOE NUMBER <br />MONITORING PERIOD <br />YEAR MO OAY YEAR MO DAY <br />FROM `I '! 1^ O1 TO 9R 1? 31 <br />1167/1 111-731 111-751 !16171 (78-791 !363/1 <br />ut•tiT !• ;' r ' <br />yl,~~:. <br />Form At ~ad. <br />. OMB ~ 0-0004 ._ . <br />Approv ~ree ~05-31-f18 <br />,,NOTE: Read Inetrualone balora edmpletlnp this form. <br />PARAMETER (3 G,d only) QUANTITY OR LOADING t4 and only) QUANTITY OR CONCENTRATION ND. FREQUENCY SAMPLE <br /> !46531 1546/ !38-15 /0653/ 154.67/ % OF <br />137-371 E 'W'LLYAS TYPE <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS !F7-eJ! (54581 I6?)O) <br />~.1:• .i!iv I);. Ic.. SAMPLE n¢:;u':r,: r: r: r:,:r.:~ Ir ;.:~r:~:~:-: <br />~ ' ; 17 1 MEASUREMENT <br />c, 111'c :. 1 •,) sI :~~PERMIT ~.: .:. .c;T f: ~~~f {:. .. n~.. ~'. ~ <br />' 'r:7=] '.r is>; nr, r::, rr fp Krly i:: f::' :: ~i n,. ;: ... r.: <br />•.. <br /> <br />.. <br /> <br />.. . <br />.. <br /> <br /> <br />:.... L. ~: <br /> <br /> <br />.5' ~~.: tr .^. <br /> <br /> <br />: ,.I <br />- ,, ,. L..,~:- r I REQUIREMENT :. . <br />.. .:: .. . <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />~~~~ PERMIT ~ <br /> <br />.. .. <br />~ ~ <br />~ :: <br /> <br /> <br />~~ <br />~ ~ ~ <br />:. <br />.. .. <br />~ ~ ~~~ <br /> <br />~ <br />~~~ <br /> <br />. <br /> REQUIREMENT ~ <br />~ ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ . ~ . ~ .. ~ .. .. <br /> REQUIREMENT ~ ~ ~~ ~ ~ ~ ~~ ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> ~~ PERMIT ~ .... ... .. <br />~ <br />~~ <br />~ <br /> REQUIREMENT .. ...: ~ ..:~... ~ ...:: ~ .... <br /> SAMPLE <br /> MEASUREMENT <br /> ~~PERMIT.~.~ .. ~. ...:~. .. ...~. :~ .. .... .... <br /> REQUIREMENT ~ ... ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> :: ~. PERMIT.: ..: .~ ... -:..: ~~..:..~ ~ ~.. ... <br />. <br />:: <br />~~ <br /> REQUIREMENT ... ..... .. .. . <br />.. <br />: ~ .. <br /> SAMPLE <br /> MEASUREMENT <br /> .. PERMIT.: ~ .. ... <br />-. <br />~~ ... ~ ~~ <br /> <br />~ <br /> :REQUIREMENT. <br />... .,. ,.. <br />~ : .. <br />... <br />:.:~ ~ <br />..... .::. <br />:.i <br />.~: <br />- <br />~~ <br />~ ~ <br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I cERTIFr unDER PENALTr of uw rnAr I NAVE PERSONAUr ExAMINED AND TELEPHONE DATE <br /> AM FAMNM WITH THE INFORMATION SUBMITTED HEflDN: MO 8ASE0 ON ~ <br />~~ <br /> MY INQUIRY OF THOSE INDIVIDUK9 IMMEDIATELY RESPONSIBLE FOR <br />OBTNNING THE INFORMATON. I BELIEVE THE SUBMITTED INFORMATON IS - <br />-- r~ I,~'l~~- <br />~ <br /> TRUE, ACCURATE MD COMPLETE. 1 AM AWME TNAT THERE ME <br />SIGNIFICANT PENAlT1E9 FOR SUBMITTING FN <br />SE INFORMATION <br />INCLLgINO <br />/' <br /> <br />j <br />'1 <br />' <br />' <br />J , <br />. <br />E 1 <br />P <br />E <br />E <br />' <br />~ ~ <br />, <br />i ' I ' ~ <br />i <br />' <br />' ' ~ I i+ <br />I <br />, <br />(1 . , <br />, <br />. I ~ \ 18 LLS.G. <br />THE POSSIBNTY OF FNE MO IM <br />RISONM <br />NT. SE <br />001 MO ]3 <br />10NATU1IE OF PRINCIPAL E7LELY/TIVE 1: ( <br />i <br />) I i <br /> u.s.C. E Isle. lRerlWr rnOA. u+er mnmr e1+Y ~~r+ a.., w ro t rO,OpO f AREA <br />TYPED OR PRINTED Wsmui+rue Mplimnr~rderrwwn Fmma. rMBre+,+l 1 QFFlCER OR AUDIORIZED AOEM CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reverence s// ettecllments Dersl <br />,d1"fLLhliLc `.~rt~l.i;S i.I NT.I hF~YLI r'; ONLY IF C= lU-YC, 24-tiff PP. P.CIP P,V F.9T IS CLAT"±~:"~. 'F' ''1 !~1"' ,~I~n DnL~;: ~) rv <br />::_l.C+ 'C:;i I~ (PO!: L1 M:~I~C~ uLLI. `I01' ~aE APPLIED TQ REVO,oTF.U ,vFASURF'MENi3--5P.i•, I+F'+l Fr rr:: !! ,`111 j+t'+tl;r !':- f+ <br />EPA Form 3320.1 108-951 Previous editions mey be used. /REPLACES EPA FORM T•40 WHICH MAY NOT BFr USED.) (,1 n ~ II P, / ~ ~ n 7 l ~~ - 1 3 f 1. ~ PAGE OF <br />