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PERMITTEE NAME/ADDRESS (include Fnailip NamelLxarinn if Diffexenq <br />NAME <br />CYtz'*US YAf~e F 7diL=_Y :(7n:, Cn,!I'. <br />ADDRESSgItiEg 1.1:;-1 SCUT:.r `~ rC".t'e.'J PK <br />yiUU F.A-;2 r"IF~h6L Cii'CL~ <br />FvGL6M00D ;Ti: aU15S <br />FACILITY <br />LOCATION <br />F.7T:1: "tUStRI5 N. fi:,GL~Y, ~ ~r,'r'.RAL R7NY <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR OMB No. 2040-0004 <br />rz rsi n>.;s) '1 A J "> ~: 444 <br />r r,0D77 SO 005 y Approval expires 0537-96 ~ „- <br />PERMIT NUMBER DISCHARGE NUMBER F _ c I ~ A L HO I, T <br />MONITORING PERIOD CH P.OHIC wY:T 7P. S'[ING FCi-. OUSA <br />YEAR MO DAY YEAR MO DAY ' <br />FROM '!'T u u TO UU Uti JU '~'•`•"° '10 CISCHARGF ~_~ '=*~' <br />(zo~zll r2z zs) (za~zs) ns-zvl (zsas) rTS~s1) NOTE: Read Instructions before completing this Corm. <br /> (3 Cab Onry) QUANTITY OR LOADING (4 Cero Ortry) QUANTITY OR CONCENTRA710N NO. PREOUENC SAMPLE <br />PARAMETER (46-53) (54-6T) (38-45) (46-53) (54.6/) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />Isagl ANALYSIS <br />(64-68) <br />69.70 <br />6. FYECT '.:TATkE 7DA'f SAMPLE =;:fiY~X:rr #CferA„es p##',:r_[: >r,-#~}0;; ( 23) <br />1 <br />T'ik C;.~t;IOUAPHNIA MEASUREMENT ~ ~0~~ Q z ~~bg <br />"CP3d U U PERMIT MAIfiO+O+O '.1~!''M ### b~q;: $7>@1k~r0i. ICtC/;>MyCri.p ER ,Q ~AI.Y R~4' <br />ifE CU'1 .'F RTS 9E LOY R~t]UIREMENT~- r I(`` vs,°, 1..T'~wt ~~.... s~'e' 9##it _~ ~~.. -~~. ;i;~'. +` i -~,t-~ EKT ~' n <br />~ ar r,. ~, <br />6 ^c F'FFCi .~'tATRE "/DIY SAMPLE #4#O#~4 <br />~ #0>flR r?IP <br />IOO,a #C#3## fity### ( 23~ ~ <br />- <br />~ <br />:f-k PICLFHALP;S MEASUREMENT > Q Z qg <br />tCP6C _, U U PERM 1, o- ~l`- ~ Y O>aLr tr 'rJiz r <br />' <br />' ~ ~, - ER yf=",~I r "~, "• Y7~(%Q <br />3~Sf. CO.°.",~fITS SELON REDUIRE <br />E~1T t -t~~? <br />~ <br />~; ~y~t+4 I~IE ~~1~} <br />F1~' ;'$~[~''t,+al• P <br />~ <br />, <br />~ ~ <br />;~ <br />~ <br />;tf CBNT ~'I t'?mw <br /> „ ~ <br />. . . <br />. . <br />.~;, <br />.'r r ..: <br /> SAMPLE <br /> MEASUREMENT <br /> .•:PERMIT ~ - <br /> REQUIREMENT ~ ~ ' <br /> SAMPLE <br /> MEASUREMENT <br />- PERMIT ..'; "-/'~' vF ~ . ilr~n ~" ~ ~ - . <br /> REQUIREMENT' . "~-:'- ~ ~++.'." "" ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> ~ '` <br />' s .~ .. <br /> REQU REMENT ~`~`~t,". ,-~.P <br />ly~ <br />" <br />9~~~€ <br />~ ,l l• <br />. '"y <br />~~ ~; <br />a:' .~ <br /> +K <br />[ . V <br />. . <br /> SAMPLE <br /> MEASUREMENT <br /> `' PERMIT - -ra ~ ` ` ~ - - - <br /> REOUIREMENT <br />r. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. - ~ <br />- ~ ~ .~ ~ - <br />~ <br /> REQUIREMENT ~ - - . <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER 1 CERTIFY UNDER PENALTY OF LAW THAT 1 HAVE PERSONALLY E%AMINED AND <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN: AND BASED ON MV TELEPHONE DATE <br /> <br />Richard M(Ils INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOP OBTAINING <br />THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION IS TRUE. ' <br />~' <br />~ <br /> <br />l M ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />BMIT <br />RORMATI <br />INCLUDIN <br />E <br />F <br />G FALSE <br />THE ~ / <br />~ <br />97O-B7O-Z7~I <br />anager <br />Environmenta PENALTI <br />TIN <br />IN <br />ON, <br />S <br />OR SU <br />G _ G , <br /> <br />POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 U B C. 4 1001 AND 33 U.S.C. <br />P <br />m <br />r <br />l <br />n <br />N <br />i <br />h' <br />ro YIO <br />0c0 <br />3 <br />8 <br />' <br />C <br />d <br />SIGNATURE OF PRINCIPAL E%ECUTIVE <br />~ <br />' ~ <br /> <br />TYPED OR PRINTED eneai <br />es un <br />ar <br />esa sre <br />u <br />es maT i <br />r <br />a <br />nes up <br />, <br />en <br />a <br />1 <br />. ( <br />c <br />4 + <br />maximum ~mpnsrnmeraal SeAseanBmoMhs antl5yeen.) OFFICER OR AUTHORIZED AGENT AR <br />D <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS ANO EXPLANA I I V N Uh ANY V I V LA I I V NJ (h'BlerenCe all aRBCOmenfS ^ere) <br />'~: L.r3.4 POF TEST PHOCELUFE. HPT ?2S[1L'f5 CP 1.ET9ALIT'f DFitIVAT"f OR ; AS "FFfEC'"O, ;kGVeTH E REFRGJUCTIOti <br />DtRIVATIJHS AS 'rT0%ICiTY". RPT LOW°.T 71 EE'FI. aT kHICI! STA.TIjTICALIY S1:!vIF UIFF BET1rEEN TEST ~ C(1};TRilL <br />r~ur oov vn n4TUI- mecT ___ne ncrnnm r~ _c~ m_ccT n~ennr-"nnr ~~.-r__nt .n o.___ mn ny~ <br />Epp Form 3320-1 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) U 0 06 4 / 0 0 0 4 0 5-1 501 PAGE I -OF <br />