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<br />LOCATION -__--_------ --- --
<br />ATfli; RI~kiARD G. P.TKiM>ON-
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<br />D ISCNARO ~DNITORIHO REPORT /OMRI
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<br />-ERMIT NUM BBR ~ ol.cNwwc[ NNr.[w
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ' ,I TO V I
<br />1I0~11/ 177-13/ (11-73/ 1161 1 /78191 /3Q 11
<br />."f I t~ O q Form Approvd.-~~ l
<br />(S U ;f H' N W) M (Opl)9TNo. 2040.0004 \„
<br />F - FINAL Explrea 9-30.91 L
<br />GAREHOUSE SERI TO Y9YL')R CPF.EK
<br />NOTE: Raed infVuetiom before eompletinp this form.
<br /> (3 CeTd On/Y) QUANTITY OR LOADING (1 Card Only) OU ALITY OR GONGENTRATION
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<br />PARAMETER
<br />(1673) (316/)
<br />(l8I3) (1613) (y1-Bl)
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<br />NAME/TITLE PRINCIPAL Q[CUTIY! OFFICER 10[RTIFY uNOFA RNALTV
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<br />AND AY fIMILIAR WITH THE INFORMATION SUBMITT[D N[R[IN AND BASED TELEPHONE D A T E
<br /> OM YY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLC FOR ~
<br /> OBTAINING THE INfORMAT10:1. I BELIEVE THE SUBMITTED INfORYATIOM
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<br />NIFICAMT RENALTIES FOR SUBIJITTING FALS[ MFORMATgN MCLUOING ~
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<br />SETTLEp6LE SnL7D5 LT"IT A,P:LIfS Ot7LY IF <= j0-Y31 24-HF x'RdCIF F,YE9T I~ CL9ICF.D. TF CLAI;1 APPRUVF,D 9Y
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