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PERMITTEE NAMEIADDRESS(lnduds NATIONAL POLLUTANT DMCHARGE ELOMAnom sYsum pY mm <br /> Feaiy&%mWLocaWnlfditfemmnt) DISCHARGE MONITORING REPORT (DMR) <br /> NAME r Lp (2-16) (n-1e1 Form Approved. <br /> ADDRESS1V COO— — Minor OMB No.2040.00" <br /> NUMBER G NU Approval expires 10.31-94 <br /> F-Final <br /> CLA1114 MONITORING PERIOD <br /> _LOCATION UjjjU M � �]ASZ1 (Lpu— — YEAR NO I DAY YEAR I NO DAY NO DISCHARGE ** <br /> ATTENTION ' FROM 01 1 TO J <br /> 20-21} -23) (24-2s) (26.27) (26- 9) (3"1) NOTE: RwA naauenons befbm completing this form. <br /> FMOUDICY <br /> PARAMETER (3 Card Only) QUANTITY OR LOADING (4 Card Onry) QUALITY OR CONCENTRATION NO. OF SAMPLE <br /> (32-37) (48.33) (54"B1) (36-4a) (46-M (54-61) EX ANALYMS TYPE <br /> AVERAGE MW UNUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ITN ( 1 (69 70) <br /> SAMPLE #***** ****** *****# *****# ##**** <br /> MEASUREMENT <br /> PERMIT #*##it 00.OAYAVG <br /> REQUIREMENT *#*#** **#* * ****#* <br /> SAMPLE <br /> MEASUREMENT **###* *#*#** ***##* <br /> PERM #sit# *# * **#*** **s*sf 304DAYAW67 **rA*1i <br /> REQUHIO ENT slog I# ** # #**a2*# <br /> SAMPLE #*###* *#**** *****# ***#** **>*** <br /> MEASUREMENT #****# #**#** ##**** <br /> PERMR *## # 30-t'1AYAVG tt>M# * <br /> REGU REMENT <br /> SAMPLE **###* #****# ###*#* ****** *****# <br /> MEASUREMENT *#** * **#*** *****# <br /> PERMIT ###*## ****#* t*iR**# 30-DAYAVO *# #** <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ****** ****** ** ** <br /> PEIOIIT **#*#* ###### ****#* #**## 3"AY AVO #****# <br /> RENT ****## ***#*# #***#* <br /> SAMPLE <br /> MEASUREMENT #*#**# ##**** *****# <br /> 3aurl►1�ll,Vci * ##*# <br /> SAMPLE #*#*** #***** **##** ****#* ###*** <br /> MEASUREMENT #****# *****# **###* <br /> PERMIT . #*##*# ##lee# ( *#a#* ## *:# 3"AY AVQ ####*# <br /> REQUIRIMENT ####t* #*#*# <br /> NAMMEMTLE PRMNICIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND TELEPHONE DATE <br /> �. _- ( C .�„, ( AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN;AND BASED ON MY <br /> Z"� tY�VJ INWRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAIMIq <br /> �� p THE INFORMATION,1 BELIEVE THE SUBMITTED INFORMATION IS TRUE,ACCU- _ <br /> l� RATE AND COMPLETE. 1 AMIN AWAREFORMAT THAT THERE ARE E POSGWT PENALTIES _ ` ��,� �� 'A} <br /> FOR SUBMITTING FALSE INFORMATION,INCLUDING THE POSSIBILITY OF FINE � J AND IMPRISONMENT. SEE 1S U.S.C.M 1001 AND 33 U.S.C.S 1319. <br /> TYPED OR PRINTED ftnWes under proles sawMs they lnotrids lhas up to S10,000 and or madmum TORE OF Mo L AREA <br /> #np iwnmsnt oltrohwsn a monMs sd pysaro.) OFFICER OR AUTHORIM AGENT CODE NUMBER YEAR MEO DAY <br /> ( Y <br /> ;l R�41Jr�ALL G' �I,�'S QXCLIRKO Walt' Vf�- SITF. <br /> • gPAPMM 33MI MEV.54M PMWmn o0i maybe wed. IREPLACES EPA FORM T40 WHICH MAY NOT U USED) 000051950316-1633 PAGE 2 OF 2 <br />