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<br />' LOCATION
<br />ATTh: RICRARD G pTPIH50N
<br />UIbCHARG NI'IORING REPORT IUMNI
<br />1 10 17.19
<br /> cocnsoo» ol.~s ,a
<br /> PERMIT NUMBER RncwAwcE nowEw
<br /> MONITORING PERIOD
<br /> YEAR MO OAY YEAR MO OAY
<br />FROM D u ~ TO (
<br /> 110111 11113/ !16131 !Ib-17/ l18~19/ l34 /
<br />1
<br />!? ; Y C fi Form Approv
<br />(SUf3fi NU) N(O1NtdTNo. 2040.0004
<br />F - FI t(A L E%plres 9.30.91
<br />STOREfi COAL LOpDOUT/SAILOR CR
<br />NOTE: Read instructions before eompletinp this form.
<br /> (7 Card Only) pUANTITY OR LOADING (1 Card OMy) OU Al1TY OR CONCENTRATION
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<br />PARAMETlR
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<br />(!1.37) E% AN wL r515
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<br />NAMC/TITLE PRINCIPAL [%[CUTIVE OFFICER I CfgTIFY UNDER PENALTY OF LAw THAT I NAVE PCg50NALLY EEAMINED TELEPHONE D A T E
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<br />ON MY IIgUIRT OF TMDSE INdVIWALS IMYE011TELY gLSPON$IBL[ FOR
<br />OBTAINING THE INFOgM1TgN I BELI[VE TN( SUWITTEO INFORMATION
<br />IS TRU[ ACCURATE AND COMpIETE I AM AWARL TNAT THERE ANE 510 `~r~7
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<br />THE p0551&LITY OF FINE wND IMpR50Nw[NT 5L[ 1B USC f 1001 AND
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<br />33 USC \ 1319 IRnRinr. uMrr 1Arr Mwrybr m nrludr /inr Vy O• !/n IMI
<br />r SIGNATURE OF PRINCIPAL E%ECUTIVE
<br />TYPED OR PRINTED a.d~.•IIIRaimwn lnpn.,nnl.nr~./Mlu..n AmnnlA. and +•.wr.I OFFICER OR AUTHORIZED AGENT A A NUMBER YEAR MO DAY
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