|
HMITTEE NAME/ADDRESS,Du.9idr Feril(tt Vamr.Lrrgli nn if Differeix,
<br />.''.LIE
<br /> v
<br />1
<br />
<br />i ? .
<br />;-ATION
<br />T
<br />Pdr- I,
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM TO
<br />
<br />NOTF• Rt+ar1 Incfr..r•tinno her.. . .: •r,:. t,
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY
<br />OF SAMPLE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE
<br /> SAMPLE ..
<br />•
<br />} ::
<br />
<br />MEASUREMENT r
<br />,
<br />., ;.
<br /> PERMIT
<br />
<br />
<br />REQUIREMENT
<br />'-'r
<br />-:: ?.'lt".•?
<br />.. n
<br />fJ.
<br />Xx-z :C G.f
<br />??. CJ
<br />1W IC E! F
<br />'t'L•
<br /> ,-t, t
<br /> SAMPLE
<br />
<br />MEASUREMENT :•
<br /> PERMIT
<br /> , ,I _':i•f ,.,}.
<br />t .. :r } t4*4i ' -
<br />
<br />-
<br />REQUIREMENT • -
<br />J l.r*1
<br />L/ ?F.AII
<br /> A4 i
<br />f
<br />i-E
<br /> SAMPLE
<br />
<br /> MEASUREMENT
<br /> PERMIT
<br />
<br />I .1
<br />REQUIREMENT
<br />
<br /> SAMPLE
<br />
<br /> MEASUREMENT
<br /> PERMIT
<br /> x:; ?,t i3 r A :: r a cif 4k't txx f i;Idi Ii?t i???3
<br />_ REQUIREMENT -
<br /> r t, l
<br />OR SAMPLE
<br /> c_ _
<br />!--AN"
<br />MEASUREMENT
<br /> PERMIT
<br /> tjf•.l ` T iV l )."1
<br />If
<br />9
<br />- ?..- REQUIREMENT ,
<br />1
<br /> ;I.
<br /> SAMPLE t?t tt :? ::.: a ?,, •,
<br /> MEASUREMENT
<br /> PERMIT
<br /> a ;r z ?? I
<br />-''
<br />'r1L
<br /> REQUIREMENT
<br />
<br />i i SAMPLE -r d fi ro ( oQ } , ;
<br />
<br />MEASUREMENT i
<br />l :t;*
<br />I SUAl
<br />F: 1 .1 - PERMIT
<br />REQUIR
<br />I 7-
<br />EMENT -,
<br />T
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I...tir..mdrrpru.dt...rI.,.ii,ii i.d '. ...rmamlau:alnrhmrnt,..rrr
<br />
<br />pre-pared andrr m. Atria lien ur ,ulnr. i•um m au,ud.nu. w.16 a .. Him de,i?md
<br />TELEPHONE
<br />In a„ur
<br />Ih
<br />l
<br />f
<br />l
<br />d
<br />DATE
<br /> r
<br />u
<br />qua
<br />.
<br />tr
<br />jw"-itrl prupr.h dal brr and r.altjat, II)r AA..nnabun /
<br />! -'s V •-iL. wlnniu.rl. liu,rd on nt. inquire of tAr p.•nnn a Orr .n, ehn umm¢r Iha y,trnt.
<br />or th,.,r
<br />w pit. dir
<br />IN
<br />i jrj -- ?
<br />?
<br />
<br />,... I
<br />r.
<br />rr,l..?m
<br />hlr r..r gal brr. m: II..' infurnr..i iu i. 11r ;nfnrmatiwi
<br />,ubmnlr.l i,
<br />I.
<br />h
<br />h
<br />. ?? r•
<br />' '
<br />.
<br /> .
<br />. t
<br />r
<br />r,t .d m. Mnmlydyv:uul Lrliol, Into.:.. curwr. and r..mplrtr.
<br />I
<br />`
<br />
<br />TYPED OR PRINTED ...........r. ?"'I .h. m..r. ,.cnirk.nt
<br />V•'n:dnr, /or.uhnu Fdv .nlnrmatinn.
<br />mm
<br />N S16.
<br />NATURE F PRINCIPAL EXECUTIVE
<br /> .o.
<br />.._ I
<br />, pn..;6dil' 16n, .uul ;mpri...m.n•uI ha Lo....inC OFFICER OR AUTHORIZED AGENT AREA NUMBER YE
<br />
<br />COMMENTS AND EXPLANATION OF ANY VIOL
<br />ATIONS (Reference all attachments hvrp.)
<br />DE AR MO DAY
<br />!LF-:AI3LE 90L D'S L1M.LT WAIVET) F'0R It
<br />I. P. u. ANY ADE'I7 10NAl_ ? ,'• ;?i.
<br />_ - sed
<br />ECIP EVENT SUBJECT TO BURDEN OF PROOF RECALITREMENTS
<br />TC THE DIVISION WT-rHTN 4R =-tram
<br />y0 0, lhi.,:ir i0-tmv. ti,m?.
|