|
<br />PERMITTEE NAME/ADDRESS Jlnclude FaclGt)• Namdlwadon i(Di$erenq
<br />NAME ~ .~
<br />FACILITY ~" -~ h'. I. i ,. ~ ~ , ,.~ ~I ~.
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (OMRJ OMB Nn. 2040-0004
<br />? ': )
<br />PERMIT NUMBER DISCHARGE NUMBER .. _ _
<br />: L ' ~ L '.
<br />MONITORING PERIOD ~ - . .. -... " I J ? E ~ ~ A 5 ..
<br />YEAR MO DAY YEAR MO DAY ~y ~~
<br />FROM ~ , ~~, , , Tp ,,l i '. .: ~,; . is q .. .. -. ~ ~d1Ti -~.,r
<br />~~ NOTE: Read Instructions beto a plating this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETE EX of TYPE
<br />R AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANUV5IS
<br /> SAMPLE .. .. .- . ... .. I ! ' )
<br /> MEASUREMENT
<br />;., -I ; i 1 J L PERMIT tau##?# . 4r#4### .. . S #+YrOL~ r3 . <Z r Y KS-~t'~U
<br />
<br />.. . ~
<br />' ': L ~ ~ _~ -, ~~ d L'.t F, REQUIREMENT t
<br />p , y f 4 i.
<br />.. 1. ~ r SAMPLE .. ~...:...
<br />~ .... ..........:.
<br />.... '::.r f: r::::; •: ( = ~ )
<br />p,:) MEASUREMENT
<br />
<br />u _r I 1 ~ J
<br />PERMIT
<br />a##Artt¢~
<br />xt#+Rt[#R~
<br />~li~#b##
<br />'~j ~ kS.
<br />D
<br />~ i.
<br />€~,~'`.
<br />~3~
<br />, i ; ,J! r ~ . REQUIREMENT .. ~, . ~ "
<br />... [ ~ . ~ , ~ I"' L r .... SAMPLE `: -.:: r:.c .. .. r,. ~ i::, ~ ': ( , ~ )
<br /> MEASUREMENT
<br />' '~,.` 1 J ~! PERMIT +t;~R#~R" R4~>k-A:P C ::.•- +Rd4~4A# R$RORT SBPART 0 I~
<br />f`r~~"' ~'~M~
<br />F •' : '1 ~ . i J S `> 'J d ;. ' !• REQUIREMENT ~O O ~. ~ . ~
<br />JI.. ~ .:'~ , SAMPLE ... - ., .. :pa^;<'- ... ( l ~)
<br /> MEASUREMENT
<br />~,~~, .>'~ 1 ) is PERMIT 4#le drR# ##+P#ar C¢ .-~+R ti### sat#ta#xr U C M3~'N~" 8!.
<br />8`~
<br />I. ; =.. ~ L' ., 2 J:i •! A L ~J `_' REQUIREMENT - N•-.. _
<br />.'' . .:i f •lL SAMPLE .. .. ... •:n:;'.: . ~ ., - ( ~ )
<br />I A ~ r) MEASUREMENT
<br />-1.'L'= ] .) "PERMIT Ata"+9t'6# #+1r +'kxA#~ R'kRd1Ce# ,Q ',,Q ~ ~ ~"~". ~A; ~•
<br />• ° : ~ P % J S 7 ~'. ~; .; REQUIREMENT -
<br />!. ~ r:r _ ~. ,i! ~ SAMPLE ( "3) r$r}{<r;: r: ... .. ..: r.:;
<br />~ , ~ .~ -: ~, ~~ , ~( MEASUREMENT
<br />..~J i. J PERMIT i;K~Q~~ ~~•$~PU RT #'4 ' '[ YIi{f4R=L:k :;~q~LMi~ ,'z' - ~'.-Y~ ~~ 1i
<br />_ ! JAL •, ;, REQUIREMENT ,1 (I A A Y> ~ I Li t1 X ''!
<br />i; ~ .. ,;,.. SAMPLE ~.,, •. ( "'I) ... ........ ... . .
<br />
<br />• MEASUREMENT
<br />i. i PERMIT O+kdtOt{t~' Y ,. ~ =i OGAt#=F 9c ####ylhdl #Qepr!a#7t_.,... .~:SI ~LT ISbAL
<br />~• '" y 3 L .; r: REQUIREMENT ~•- S S T R A X
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Caddy untler penalty of law that this document and all enachmenLS were
<br />r
<br />tl
<br />tli
<br />di
<br />i
<br />I
<br />tl
<br />w
<br />h
<br />t
<br />tl
<br />l
<br />d
<br />d
<br />'~ TELEPHONE DATE
<br />~
<br />~~
<br />~'
<br />J p
<br />epare
<br />un
<br />er my
<br />re
<br />on a supervrs
<br />on
<br />n aaor
<br />ance
<br />a sys
<br />em
<br />es
<br />gne
<br />A ~
<br />i-r, !.
<br />u.
<br />/ U~i to assure that quaLfietl personnel properly gather and evaluate Ne mlpnna60n /i%
<br /> submitted. Based on my inquiry of the person or persons who manage the system, -
<br />'
<br />- or those persons deadly responsible br gathering the information
<br />the Inormation
<br />" ' - ~ I ~
<br />~ ,
<br />tl i
<br />k
<br />f
<br />b
<br />i
<br />h
<br />b
<br />f
<br />l
<br />d b
<br />li
<br />l [~. ~ ~
<br />Z
<br />~
<br />-
<br />.~ now
<br />su
<br />m
<br />tte
<br />s , to t
<br />e
<br />est o
<br />m
<br />e0 an
<br />e
<br />e
<br />, bua, accurate. antl comp
<br />ete.
<br />y ~
<br />lti
<br />I
<br />h
<br />h
<br />i
<br />f
<br />b
<br />i
<br />i
<br />/
<br />l
<br />i
<br />b
<br />d SIGNATURE OF PRINCIPAL EXECUTIVE ~, i
<br />~ . , i')' -R' %
<br />n G'
<br />' ~:
<br />-
<br />TYPED OR PRINTED am aware t
<br />at t
<br />ere are s
<br />gn cant p¢na
<br />es
<br />or su
<br />m
<br />tt
<br />ng
<br />so
<br />n
<br />rma
<br />on,
<br />a
<br />Inclutlin the ossibili otfne and im risonment for krgwin Notations. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />GOMMEN I S AND EXF'LANA I IUN UH ANY VIULA /IUNH (HerelenCe a// attaC/7mentS Here)
<br />... L. .'r V, .).. d;ril'c:.i... lTl .. , '._ ?["J?I':B"_,'~:.. i. ;i.~.s' ~ V)!. ..iSr.LY i~'.,.!L7' .
<br />EFA ~~orm~3320=i ( 3~9A)- Prevfous`e~itions`may ba used. THIS IS A 4-PART FORM PAGE OF
<br />^OiUT/GJ0717-iSJ i
<br />
|