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PER_NAY /I_ fx;rgN.meR~mr' y _. ~ON T ARGE ATIO M(N!_ . ~ ~fSCf1A ITOR~POR1 - ~ _. ' '~ _ ~. :- ~ • ~ NAME ...dcAL C0:1PAtiY ...' :.' ..._ . . _ . ...~ •. .~-1...... n7-ro~. . .: =,FINAL..-:! .•.:-... . £~.:.= ADDRESS ~fl•yAA INES ~ - - ' - ---_-- --~- • - 'COG~SL'015 '~. ~- :~-.UUU-.-:B=:-~:' _ . __ "'POHa~-4~-BfJ~O F.; TC CU _ _ _ P _1.tn.~....: P.O._yT~("S Z8 B~ _ ''~' '.p"_~ _ _ ' v ~ Y'. PERMRNUMBER - u a DISCHARGE NUMBER :.. _.'.. -`7. .::'.:.~ .-O ~ - " i ~ ~ z ~> , °;tz PERIOD.a -.;.:~. .`?`: MONITOBING ° g ~;~ f":r• 1-"~ t A FACILITY ~ -~ ~' .~ c :.•R /w: '+i ~. o,.: -. ', a .~ ~.. .... ?~ .. t> . _ . .. o':~ ~" -: '~ '~ -: ;~: a:r-~'.: a:~:~~. _1 LOCATION-_-i3 ~ o ..: ~ ~.-; ~ _ . . 6 v:- 2 YEAR 1 MO. -.D : MO. DAY tY R :FROM .. - ~~ - .~ _TQ ". y., ... ~ . Q - i1 iQ(f ~. ,.~ U~ ~L',~G ~' ~.~ A . d .. A 9 ~ P H~ 9 ~: 7 ~! G P. ~ ee , , , , . ~ . /zo.ul= 111+731 r1~-111 ,~ ~ ~rt4v~ a&avl 134311-. : ~ ' ~ NOTE Read InatrucUons tieforB ec ~d :T~ Mo. 20aPOOw ~ . r. this-iorm.~~~ ~, rr .. ~ - -' ~ - ~ (3 Card OrJy/ '-QUANTITY OR LOADING -, 1 • ~ ~ (Card Only/0~,;. ". DUALITY ORCONCENTRATION-:, : ~) v °'^' NOJ F$EOUENCT ~ ' ~ 1'~ SAMPLE u - PARAMETER' _ ~~ •• ~ -..~ .,~.r. i '~ 1KJ31 (JI-611 ~ O C~' Z .R ~Se~ -O• (38151 C. _.:. (I6-J31_• •. •r (SS611.. ~• j' _'„' _ _. .. .. _ .~ 9~.• -TYPE - 131-37) J .< ' ~ ~ ~ ~ ~ ~ ~ o ~ N ^ AVERAGE .. _ h v; ~. MAXIMUM UNITS ~ m _ ~ MINIMUM; - AVERAGE - ~ : MAXIMUb~~= r ` ~ U.., A11/1-L]'$I$ ~ UNfTS ~ , it _, 7p q ~ v . ` . .. _ . '. , : (61~ rJ6«I . - ~ (6 - 1 t:iL AyL• lih~'A~SY ~ _ Q~~ _ SAMPLE:.;- -?.'O:7.y+A' y . ~~ a_ o'.p •-- v tr O v Vif:+M :::f a..". .. v Y~V :t=A'Y <~ ~ -i:Gt-4 - + YY ~"' a'pa ~.Qt _ / ' . pc ~` - - ~' _ u 'USUAL - .. '- ~ MEASUREMENT ^ - C i _ iY - rt i' O ~ N-< - t ~ C T ~ G A Q u . A u' - Y_ . ' C-~_ ,, 41-, ~rL :'~ J 7:, . A...n F ;' • : ~~ . - ` J . .. :' . .~ : ~ : .°.4 1;67 i ~ .^n t7 yt~'~. +ta ~'~ ,'J~19 .z ' "T~ FS-~°. ~ '~.4*' z'.1 90 •A -• ~ : a'`• j .n CI'-" ,M ~~.1. c9FLJE!iT G~CSS Y+L~ OUWEM~T•@ " ~ ~ ,v. ' ~Q1'' ~ ' =~ "} '~ ,~,~ l .'u '~ X ~ Se L~ ,,: ~~$ > N1 a _ _ _ ' ~0 i .. r ~ ~SAMPCCy'. is =_C_. ..: ~ /~~ ~'<: G T •.' - O. ICi,:.~ _ ;~. v .~: ^, j'.,,.7 ~~.-m.-,- p : p _ . /) :fro __J...Y ~ .-..: .. MEASUREMENT - _ _ :1 ~~ . . + - _ ~_ .' vY ' ,. -~t -~ r" ~ i ~ ,,,~ ~} _ , . . .. Dr ~ ... _ _ .. , -.~ - - ~ O W .. ? OUI N7•- ~~ ~ '~ a...-_. r f v d •• ' .,,_x2 v Y'764 m .a , _ ..:r IA F--- . ~ X : SAMPLED. ..~., ..,. ~. ~. ~ Jww.!.C'..- ~. ".r .. r m ']. :?,.: ~, ..~i.•r. : Z v- U ~ V L:'~w I q ~ .: '_' •~ F.;~ Lp. V r" y.~ . - _ =: ~ , MEASUREMENT d lT _. .. 4 _ U N ~ ~ ~ ~ .t ~ ' REOUI 1 ~. Ifs C rp.Giy.,. t+ C ; _ ~ ' - ~ c ' O ~ ~ ~ ~ .r.D SAA(PLEf ~. _~' .LS O' O_ :i ~ C ° .is . a .j ,F -7 ~' ~ _ :! 1~ 7 ~.-tq I - + ~. R: =..~ 'j.: p ' O ":', - ,# ~ h h ~ : u MEASUREMENT u - u ~ •a C 5 a: ~ G . Yq . ~ ~:.4 m G>yQ .7. ~ G ~ ~ .PE(iMLT nS't... ~~y,`~ ~ c1` ti !~ `. ~ O ii.:.~; ` Lei .~ - v .!] ... .. .J. .. ,-L r J - ~ - ~ - ' .~' ~ ^ ' ~ .- ll' U ?ry ~ ~ ~ Q. J'-. !'~. -.. r i' Jtl: ).~' • ~ . .~. ~ P p ~ r fa -. MEASUAEMENT- ' . . `b - _ 6 L ' ~ - i - u- ~'- ' ~ p M . _ I~1 a.= : ; y _ L` ~ O'~ _ _ ~ . _ . _ - . : . ~tr ~ " ... ' '-- _ ... _. O.O U .. E ..~SAAIPLE--». r c~i .C~~._~-cv..` .'r}.~; LLi~'~.a. " .~.~: •.q w ~ ? a ~ _ `r ~ ap M .a me ' n:;ih;'-.': ?r .. Y-~ ~ ~ ..tj,. ;,,~a-n ~. J .. : ~~~ _^ 777 ~J. I'. O N `V 'MFARUBEAI NT ~ O v A "; Y; l; 7 y . ~ .. ] '~-i ..,j ~ ~ ~:~:~~ p ~ O !" S ' ~, _ tl[ t~ V ~.+~. ~nt> .] O a ~ ~ B E O ENT U JEM . . vim , ~ *;~` 1 ' ~(y ' ~ s. ' r ,r ~ae- . - .'~. _ .~I , , : . .~ „ ~ t.~ ,ja _ O t_~ "SAMPLE ~ 5 ~ J .: .~ .r.. .' _ - W = Po _ _i._ ~.= V .r ~.. L ' ' ( - _ ~ MEASUREMENT _ . L _ A u~. ti - (. C } j.fR - .ro. ., t ~ s _ _ ~ `a PER7IR. ~ ' . n •-~`••. -",.i`'~-~zr +Lr 7= s :: •,~' `A'.Z7-'"•. ~ ` .4 ~ S.'-it:+!°.:`.~ ' - _ +•. ~~~lr ~'LY!°L {_~ "Z~r>~.-' :n L+:' ..~. i:'p'1''.-_-~'.:;"-~_ - v:- ` / 2 R: > : ~ ' ~. -- _ fG v ~± a z :'S- ~ ' - _ 0 _ ~' ~ i ~EOUIREMNNT .O Y .~ ~ 1 t ' -_ - ~ ~ ~ fi ~~ ,~.w . e .e ~ ~ + . ' _ . .r _ t.; ~ + = ' v O C -r+V _ •+r.~b• .+i+. se• t ir r. ?^ n. ""'f .+.rl.~S-N k . NAMEITITLE PRINCIPAL EXECUTIVE OFFICER - 1 CERTIFY UNDER PENALTY OF UW THAT I HAVE P AND AM FAMILIAR WITH THE INFORMATION SUBMITT ERSONALLY ED HEREIN; A E%AMINED ND BASED - - ;^ - - ~' ': ~-~~ ~ n ;TELEPHONE'. •- ~ y DATE I ~-` •' `- L ON MY INQUIRY OF THOSE INDIVIDUALS'IMMEDIATELY RESPONSIBLE FOP ~ ~ ~' ~ ' ~ •~ ~ ~ .- ~ -: -• a ~' ... T ff ~ y Gt1] Ar F,par n~ _ IY 111; OBTAINING-THE INFORMATION. I BEDEVE THE: SUBMITTED INFORMATION _ ~•' _ ~ ~ ~~ ~ ~ ~~ ~~ i~~. -' ~ r „~, .. . IS TRUE. ACCURATE AND COMPLETE 1 AM AWARE.THAT THERE ARE SIG- /'. ~ •- ~~ . . ; ~~ ~ = ~ '--.= t u- i)_. _ _ L ye$i?tnnt ~ _ ` - ~ ~ O - NIFICANT PENALTIES. FOR SUBMITTING FALSE INFORMATION, INCLUDING . _ , ^ _ ' _ _, .: , , - q ~-' ~ ~ ~ ' ~ 2 =. C ^ THE POSSIBILITY OF FINE AND IMPRIBONMENT~BEfi 1B U.S.C.[{ 1001.AND { 1J19 /Pnmllm uMn rA~ ammre mv udude lrnc u 7J U B C ro 310.0[0 SIGNATURE OF PRINCIPAL EXECUTIVE 303 ~9 9s5T/5 91. 07 G.; - "I. TYPED OR PRINTED y . . . . p, aMormaxunvm rmp.tronmenr o{trrwa6manrkrwW flevrcl ~ .OFFICER OR AUTHORIZED AGENT ... ~AR .? iIUMBER~ LEAN MO DAY COMMENTAND EXPLANA l1UN OF ANT VIULAIIUNS (HCJnvr[l au arta[AmuLS IIOYA .. - ~ "- -;, =-~ - •- FOR AZL f3% f}!I~AS=--SEc ~OQTNrJ"~ F/ I'7 2 Nir:is. S~STLS'SPLE_'Gi.ID.3 Tz':1? FEQ!JZ9:D'C!it'!~•-~$-f=-3-Q-'1~q-2(h.%!.{i~' FflEC:P °.YLY: CLA;:''.fC. Sf CLnLX P.P?SG`V?C 9'i :^CCr YSS ': S.°^,S A:L7,. !:C'[ 8° AFFLZL~C ?0 ~FPC:":T~~r,vecrlfl:'.id?_. EPA FOTrit 3320• JY• gBB) PTBVIOI/S Bd1110115 T8Y GE USBd. • (REPLACES EPA FORM THIGH MAY NOT BE USED.1 „E ` OF