2016-05-03_REPORT - M2013052

• Permit No: M2013052
• IBM Index Class Name: Report
• Doc Date: 5/3/2016
• From: Jean Marie Cowman
• To: DRMS
• Annual Report Year: 2016
• Email Name: TC1
• Media Type: D
• Archive: No

PERMITTEE NAMEIADDRESS(Include NATIONAL POLLUTANT DISCHARGE EL55INATION SYSTEM(IDES)
Facility Name&ocationifdifferent) DISCHARGE MONITORING REPORT (DMR)
NAME -C1✓r'R/ C OW I✓1 (2-16) (17-19) Form Approved.
ADDRESS 0 b S S , L.1900JX14A(D -AU 4 J COG-_C,OR 341 12.o Minor OMB No.2040-0004
000.Da 41,13QK%t.D r°2'61 _ PERMIT NUMBER DISCHARGE NUMBER Approval expires 10-31-94
F-Final
FACILirY AGA1 US Det La D6 CLhiM MONITORING PERIOD
LOCATION 18.1,itc, _Et Ipso c_QUArr9 YEAR MO DAY YEAR MO DAY • NO DISCHARGE
ATTENTION FROM —I$ O U O l TO 2.1)15 03 21
(20-21) (22-23) (24-25) (26-27) (26-29) (30-31) NOTE: Reed Instructions before completing thIs form.
FREQUENCY
PARAMETER (3 Cans Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION NO. OF SAMPLE
(32-37) (46-53) (54-61) (38-45) (4653) (54-61) EX ANALYSIS TYPE
AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS t (64-68) (69-70)
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PERMIT ****** ****s* ss*ss* *ss*** 30-DAY AVG *#****
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PERMIT ****** ****** ****** ***t** SO-PAY AVG ******
REQUIREMENT ****** ****** *** *ffttt ****** .
SAMPLE ****** ****** ****** **#s** ******
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NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND TELEPHONE DATE
AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN;AND BASED ON MY
Svt►i Llpcof— INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
THE INFORMATION,I BELIEVE THE SUBMITTED INFORMATION IS TRUE,ACCO- ea..„„‘„...__o�9p
,�Q RATE AND COMPLETE. IAM AWARE THAT THERE ARE SIGNIFICANT PENALTIES
��^Y I Imo•` FOR SUBMITTING FALSE INFORMATION,INCLUDING THE POSSIBILITY OF FINE y Q �/�/ �/p
AND IMPRISONMENT. SEE 18 U.S.C.§1001 AND 33 U.S.C.§1319. 7 1-! 3/7-Q (vc_ j5 4
211
TYPED OR PRINTED (Penalties under these statutes may Include Mies up to 510.000 and a maximum SIGNATURE OF PRINCIPAL EXECUTIVE AREA
imprisonment of between 6 months and 5yeers.) OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
COIWENT AND EXPLANATION OF ANY VIOLA110+IS(Reference all atbehmenfs here)
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EPA FORM 33211-1(REV.318)Previous edkiom maybe used. (REPLACES EPA FORM TAO WHICH NAY NOT USED) 000051950315-1633 PAGE 2 OF 2