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PE~NA E55 _ <br />Far y /Lorarlon~ //rr ~_ <br />NAME_ Ln ~C '.dL LQ°%a ti't <br />ADDRESS ~_,n t1i:~~ ___ ___ __- -__ <br />~_-ter, C~_~--_1_-__~~ <br />FACILITY _ <br />LOCATION -_--------------- <br />.'J: 'n LLL 1.1°--:iE$3r ?ii°S-GE:-v °iG ~'-- <br />_TION~UAARN~ITOEPO~R1 /N~ <br />Ali/1-I61 /17-J9/ <br />~.Jb:i~U~Ji-1 ~~1 l <br />PERMIT NUMBER DISOMARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO OAY <br />FROM ~~ „y „_ 70 ,_ _ ~_ <br />(1411) (11-131 /14-SSI 11617) /18-191 /3431/ <br />_ -Porto _ad. _ <br />_ - - OMR No. 2040-0004 <br />P ~] .'i iJ • •. .. ,.:•r O ' F "..J ,; ;; 1 .APP oval eaprei 430.81 <br />NOTE: Read Instructions before completing this form. <br /> l3 Card Only) QUANTITY OR LOADING (4 Card Only/ <br />QUALITY OR CONCENTRATION <br /> <br />PARAMETER <br />146J3/ (J4fi1) , <br />(38~JJ (16J3)' 1J4-81) NO FREQUENCY SAMPLE <br /> <br />EX " OF TYPE <br />131-37J ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 161-Q3 /6l-68) /69-70/ <br />.L :i~C 1]'i1~~7~ SAMPLE o}l:, ~v ... .-a. .~ .:a Cr-.' ;J'3 :.`. <br />S tI n L MEASUREMENT <br />::4:]OU I O Q PERMIT ~%iJl+Ll:i.'r` ~ Y .7'1 ::}r/.^.:::: ~ i=is}i:'V %4 ::iA:'::! ~l'} :£-f.L'l YSUdL <br />;: 'rFLiJE':Y 1+a.7j5 :nLUE REQUIREMENT z:vs'r nY )~~~_f~ ~:%Y,r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br /> SAMPLE ~ 1 I ` '~ I <br /> MEASUREMENT I - <br /> "Jl ~ ,\' L <br /> ~ J <br /> PERMIT <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br />' REQUIREMENT ~ - - '. <br /> SAMPLE ~ <br /> <br />' <br />MEASUREMENT _ _ _ <br />' PERMIT - '' _ <br /> REQUIREMENT - . - '" <br />' SAMPLE ~ - <br /> <br />MEASUREMENT _. <br />- <br />- PERMIT ~ .. .- - - - - <br /> REOUIREM ENT <br />.. - <br />~ _ <br />_ <br />~ ~ <br /> SAMPLE _ <br /> MEASUREMENT ~ - <br /> PERMIT - _ - ~. <br /> REQUIREMENT - - ~ - _ , <br />NAM EITITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE P ERSONALLY E XAMINED ~ _ TELEPHONE' DATE <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITT ED HEREIN; A ND BASED ~' ~ / = ~~ <br />, <br />I -~ ~ - <br />' ) <br />! <br />j <br />L <br />I_;'1 <br />I <br />( <br />' ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION <br />I BELIEVE THE SUBMITTED INFORMATION - i <br />// / . <br />~ ~ ~ - <br />- <br />. <br />~ <br />I, I <br />r <br />~1 <br />_ <br />! <br />- <br />' - ~ . <br />I$ TRUE <br />ACCURATE AND COMPLETE <br />I AM AWARE <br />THAT THERE ARE SIGs ,/~/r,r ~ <br />~~ <br />- ~ <br /> <br /> <br />r' <br />l, <br />J <br />' <br />t ~ , <br />. <br />. <br />NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br />THE P <br />B / _ <br />, <br />_ <br />/ <br />C <br />I <br />~ <br />I ~ <br />f OSSI <br />ILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.D. t 1001 AND <br />33 U <br />S C <br />p 1319 <br />/P <br />/rie <br />d <br />rh <br />e <br />s <br />r <br />i <br />l <br />d <br />710 <br />000 SIGNATURE OF PRINCIPAL EXECUTIVE ~I/i ~ ~i~ r~ r ~ <br />- /) ~ <br />.-. ' <br />- TYPED OR PRINTED . <br />. <br />. <br />ens <br />un <br />o <br />ra <br />u <br />nc <br />os <br />e mrY <br />u <br />e Ana uP ro <br />, <br />ondor marrmum imprunnmrnr o/IxsrrenQmonrheand7ymn./ OFFICER OR AUTHORIZED AGENT ~ NuMeER vEaR MO DAv <br /> c <br />COMMENT AN D E%PLANATION OF ANY V IOLATIONS /Relrrenn PI(P/rrrchmentshcre/ <br />t!]3 OIL 6-G9EASE--DEF. FOUT90T° ?/ I`7 Pc'98IT. ic':TL2A~L? SOLIDS L: ::T P°~,',t)18ED CtiL: F° <- .0-+:!r-24-HH <br />?4`CI"r' ^Vc;fT CL~_T9FC. LP CL~1I" %i!'P9Li9[iD i!Y '~QC.~r ~-S ~~ :P•0`l 'dLLL `i(Ji 35 nPFLiLD T'] :1°?C'iT~D .,2:,SU5":1:`775. <br />^. fi I _ , <br />EPA FOrm~ ,IBV.J-AEJ PleVI0lIS alII(IO/IS l1'lay Da l/SEd. (REPLACES EPA FORM /HIGH MAY NOT BE USED.( DE OF <br />