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PERMITTEE NAMEIADDRESS(lndwdeFacility NmndLocanon(fD(gGrew) <br />NAME 0 A .+ c, c q 'I' Y 1'' <br />ADDRESS C A ;, is 3 j K 7 T 19 `i I t1 F, <br />z �jF 4tY,:n f)F, IT, YE: <br />DUlini/v;) CJ :SiJ�i <br />Y <br />FACILITY it A u R I UE G ti r: R; Y I iY 4. <br />LOCATION <br />/, i TA:. 1:)3 .1. Ai1T`:11 V _ i'n ,T,'7±'T <br />NATIONAL POLLUTAN- -ISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCH2 R ONITORING REPORT (DMR31 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY I I YEAR MO DAY <br />FROM 11 •, 1 n 7 I TO I .),) -31 <br />12&21) 122-231 /24-251 x26-271 l2a-99) LWILAIJ <br />Form A ved. <br />r OMB" I 140-OQ04 <br />Approv xpires 05-31-98 <br />1'. +i L <br />F1ihi): <br />h� 'ria i' i'.� 1 ; •.1 ,,. i0 ,} tt i Y � r. r� � .. I,. f' <br />NOTE: Read instructions before CtlmMetina this form. <br />PARAMETER <br />(3 Card Only) QUANTITY OR LOADING <br />14 Card Only) QUANTITY OR CONCENTRATION <br />NO <br />FREQUENCY <br />SAMPLE <br />(46-53) (54-61 <br />(36-451 (46-53 (54-61 <br />OF <br />132-371 <br />EX <br />AN <br />,TYPE/69-70/ <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />(62-63) <br />(6¢6g/6814_'ALYSIS <br />SAMPLE <br />r::;=. .:': <br />( 94) <br />.r I ::, U r, L <br />MEASUREMENT <br />t �.PERMIT <br />_ <br />fr - i <br />e;c C,; rf r w <br />e'2 i £� �f 7 <br />K '-r" L ,:_?: <br />REQUIREMENT <br />r <br />SAMPLE <br />MEASUREMENT <br />i <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />' <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON <br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />, <br />TELEPHONE <br />DATE <br />l <br />TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE1 <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br />4 <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />1 <br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. ! 1001 AND 33 <br />U.S.C, f 1318. (Porallos under these statutes may ImAde Meas up to $ 10,000 <br />erdornwinwnknprisontnento/atween 6monthsand5 years.) <br />II <br />TYPED OR PRINTED <br />AREA <br />CODE NUMBER <br />YEAR MO <br />DAY <br />l.V1Y1MG1Y 10 AI7V Cnr6A17/%I IV1+1 Vr AM t V IVLN 1 IVI-AQ IAtr/erenue ar/ attaanmentS ne/el <br />LL :'A Li; >7LIG" LI"L!` ArLIE;3 1Ll it C= Y �c: ,C1 -if R k R mo - i`i Lli- Ir C1, . iy <br />,: .• _ . - <br />1J . �. <br />TJT E If{ u L;!!IT:i WILL 4OT 'i' R c LIF11" TU ;1EpC7'r!T;;,i 11`;it i�ic.: ;: ,r: ,__ *, Ie:{.: 4 r r• <br />• �' <br />EPAF '3' 320-1 (08-95) "PrevMs editions mey be Used. Z (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />