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PERMITTEE MAMEIADDF 'a„c,,dc i.cmry N~/EO~•nm dDlpnnG <br />NAME CI)LO~ .OhL COttPA~IY L. P. <br />ADDRESS L,C)Ln ;1INF1 <br />5731 STATE NiG!!N9Y 13 <br />NATIONAL POLLUTANT D' VlOE ELIMINATION eY6TEM /INPDESI Form Ap r' <br />DISCHAR YOKING REPORT fOMR1 .~pp,} _ r <br />zo v-la LOA DOU7 LOOP SEDTOp r Tre t~JB <br />PERMIT NUMBER DISCHARGE NUMBER (S D A R N 4i) 3 4 5 <br />F - Fi NAL <br />'l~CXCIt. CO B1b41 MONITORING PERIOD MI AOR <br />FACILITY <br />YEAR MO DAY YEAR MO DAY <br />_ <br />LOCATION <br />FROM 9g 0'I D1 TD 9A 0 0 ~'-- N(} TtTT;C4AkT-° sCl ~## <br />l <br />hl <br />l <br />~ <br />{ <br />d <br />l <br />l <br />O <br />R <br />d ( <br />'- <br />np t <br />e <br />orm. <br />orn <br />Ea <br />oF <br />LUT <br />et <br />TE: <br />ee <br />netruct <br />N <br />126YN l12-131 !1415/ 116-171 l1F-291 (30311 <br />- <br />PARAMETER I3 Grd Only) OUAN7ITY OR LOADING !O Grd Onlvl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> !4653 5F61 138-151 e653 (5461 <br />EX of <br />133-371 ANAirsls TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 1 61.6]1 1646A1 163701 <br />OII. AkU f:Rl':h`.iF: SAMPLE :k#v;frS• ( 34) ~~.••^.•~7 ~:k~:t=.t:~: t:%:::::'::;: <br />Y I `i U A L MEASUREMENT <br /> <br />VI}Ubb 1 U I) <br />PERMIT :: ...:... <br />.: $ff+"tii:`r'~...: <br />!) :::::: <br />: ::::..: <br />ES-1 <br />Et~t.. <br />p.X<m~ <br />,n~~.#Mr <br />:~~ <br />=k..;:~::',::. <br />::;:;:~: <br />A <br /> <br />SU <br /> <br />'r'.F. ~ .. ~q <br />REOUIREMEN.T <br />...: ~: ~.~...:.:~!.:..':: .~. .. <br />:.:... . <br />.. ,...~~.. <br /> SAMPLE <br /> MEASUREMENT <br /> ~.:.~pERMIT::~.~~~ ... .:::~ .. .. ~_ <br />~ <br /> REQUIREMENT ~~.~~ '~~~ ..~ ..:~.. ... ~: ~. : . <br /> SAMPLE <br /> MEASUREMENT <br /> ~~ 'PERMIT .. .. .... ...... .. <br />: .. .. .:.. .... <br />::: .. <br /> <br />.. .. , <br /> REOUIFiEMENT ..: ~ ~ ... ~ ...:~. .. ..~ . . <br /> SAMPLE <br /> MEASUREMENT <br /> :. PERMIT. .: .. . ~ ... <br />~ <br /> REOUIREfv1ENT ::~.~ '~ ~ ~ ~~~~ ~ ~ ~~ ~ ~~ ~ ,. ... <br /> SAMPLE <br /> MEASUREMENT ~~ <br /> :.:. PERMIT~~~ ~~~ ~ .:: .. ~. ~ .. <br /> ~REOUIREMENT~ ~. ~ ~~~: :.:: ... ::~~. ~. ~ .:.... .. ... ., .:~ ~ ~~'~ <br /> SAMPLE <br /> MEASUREMENT <br /> ~~. PERMIT" ~~. ...: .: ....: ...:. ... .. <br />:.. <br /> <br />~ <br /> REQUIREMENT :.:......: ... ... ~ .... .. <br />:..- ~ <br /> SAMPLE <br /> MEASUREMENT <br /> ..PERMIT:...: ~ ~ .. ...........~ ..... .... .:. <br /> ~REOUIREMENT ~ ~ ~ ~ ~~~~~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF UW THAT 5 NAVE PERSONALLY E%AMINED AND TELEPHONE DATE <br /> AM FAMILIAfl WITH TMF INFO RMATION SUBMITTED HEREIN; AND BASED ON <br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTNNINO THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS /IM/.~~~ <br />~ <br /> TRUE. ACCUMTE AND COMPLETE. I AM AWARE THAT THERE ARE E~~l~' <br /> INCLUDING <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br /> <br /> <br />rL <br />Q ( <br />~ <br />. <br />SEE 18 U <br />S <br />C <br />4 5001 AND 17 <br />THE P <br />SSIBILITY OF FlNE ANO IMPNSONMENT p <br />70 <br />82 <br />~ <br />p <br />C <br />r <br />rE,/m/ <br />' . <br />. <br />. <br />. <br />O <br />l <br />M <br />!/0 <br />1 <br />6 <br />Y <br />h <br />d <br />0 <br />0 NATURE OF PRINCIPAL EXECUTNE 1 <br />1 - ' <br /> . t.W« I <br />, <br />U.s.C. <br />1]t <br />. lhrWa <br />ww mleh• ro•r Ytc <br />. <br />• <br />rs w ro <br />0 AREA <br />TYPED OR VRINTEb •na«m•.bun EnPnmrwnr erbn..•n6monNS «d6vwrAl OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS ANU LAYLAFIA I wtv ur nrvT YtvLF~ t tuna rrtererenc~ sn srrecnmemr nere/ <br />StTTLEkkil,t i71.IUS LIMIT AppLIES ONLY IF <= 10-YR, 2~-t}R P7 ECIP F,YENT IS CLAIMF.Tt, IF CLAi:'t APPROVED AY <br />11OL:D, TSS S IAO!1 LINTS 41ILL NOT AE APPLIED TO REPORTP•.D t1EASURF,MEYTS--SEP. I.A.lA, PG q RND I,p.,1D, PG b. <br />orrn 0-1'108=951 ~ evid'ua a ItioAB y b e d. /REPLACES EPA FORM T40 WHICH MAY HOT BE USED.1 PAGE OF <br />t•Dn7-. .nn r-t• -. . ~. .. <br />