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<br />FIAIry NBRIt/ d1J/uewf/ DISCNAR 1 ONITORIN6 REPORT lOMRI
<br />tlM7s_1~ly--rnrt- rnnnl~:.y_.-______ d-!6 1719 7Lu(}}! Form Approver
<br />wDeR[t[rnr nirvn MiuF __________ -~'-I r(~I r 1 (SURR NW) M1011p TNo. 2040.0004
<br />_~_~71] STdTR_ Ht C.NY~~„3,__,_, __ •[aMIr NUMM[w onLH.R9. NVY.+R P - FI'IPL E%plreB 9.30-91
<br />~__r~j''.RR F.A ____~__~_A1fll~, MONITORING PERIOD LOA D01!'C 5%DI PONU TO M[L.Of: C}(
<br />~ACILIT7-~~~~~~~~~~~_~_~~~~~ YEAR MO DAT YEAR NO DAY
<br />~eewT1DR FROM Vq ~ •1 TO QII :)') 3(` #rt: H(1 D[SCHARGP, ~ '~'°'%
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<br /> (! Card On1Y) QUANTITY OR LOADING (1 Card Oniy) QUALITY OR CONGEHTRATION Fp EOUENGY SAMPLE
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<br /> A VERAOF MA%IMUM UNIT[ MINIMUM AVERAGE MALIMUM LIMITS 676J (~~) (69.70)
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<br />DISSDLYED' MEASUREMENT
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<br />NAY [/TITL[ PRINCIPAL [L[G UTIV[ OFFICER I CEIIIFY UNDER p[w[Tr OF LAw TNAT I NAYS F[R90NALLV [EANIN[D
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<br />OM MY INOIIRIT Or THpr[ MDIVIWALS IWEOIAT[LY RESNNSIBL[ FOR
<br />OBTAINING THE INFORMATION. I BELIEVC THE wBYITTED INFORMATOM
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<br />NIFICAMT PENALT(5 FOR SUBMITTING IALSE INFORMIITgII INCLUOIHG
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<br />SETTLEABLE SOLIDS LIryIT APFLIES ONLY IF <= LO-YR, 2u-HR PRF.CIP F.VSHT IS ~L47MF.D. IF CLAIM APPROVED ijY
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