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PERMITTEE NAME/ADDRESS (lMYdf wryA'+r'laarAwr r/Dyb.wr/ <br />NAME ., .. <br />ADDRESS ~' <br /> <br />FACILITY <br />LOCATION n ,~ -, . , <br />NATIONAL POLLUTMT OISLHMOE ELIMINATION SYSTEM lNPOES) <br />DISCHARGE MONITORING REPORT lOMRI <br />l7-161 l17-191 <br />'~}(I iIJJ rv i <br />PERMIT NUMBER DISCHMGE NUMBER <br />/ ! MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ' ~ TO ~ ~ '~ <br />• II47Il l72-131 (74751 11(i•77l l18-191 !34311 <br />rvI r~npl, Appiv.o.:. <br />1:17,7 ;-/^:'. J{t T1 'AQ'11VNOn ~~ .a R <br />^ Approval e{Igirps X31-98 <br />- 1' - : ` <br />r 1- <br />. ... ., ~ i <br />NOTE: Rud Irntruetione baton compbtinp this form. <br />PARAMETER !3 Ord Ontyl QUANTITY OR LOADING !1 Ord Ontyl QUANTI7Y OR CONCENTRATION NQ FREQUENCY SAMPLE <br /> lI6-531 !54611 l3Bd51 !46531 !64611 OF <br />l33-371 EX <br />MALVSIs TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS lF7.6J1 !6/-661 169-701 <br /> SAMPLE .. ,.. - .. ~ , 1 <br /> MEASUREMENT ; <br />1 PERMIT .,. ~.-. Se. .il <br />` l..-L.1 ~f <br />_. , . -, . ~ REQUIREMENT .. - '* F .r i . a ? A h ; "!i 't <br />.. : , ,.,C .... SAMPLE ~. ~. . , . <br />( ~" ) <br /> MEASUREMENT <br />. ~. l G PERMIT :;:.~^..~} ..-.,,y~ .. a:~;=a.~a ,.. ii.i t:CF/ 'EAU <br />... ', r .. ft) + REQUIREMENT U ', I i, -i `!'( :~ {, ! '. q 1 •; ^ ti <br />. .I :.. .. ~. :i .~~ SAMPLE .. .. .. ( ~) <br /> MEASUREMENT <br />. t C) PERMIT .., .. .~ n.:' ... ~ r. T'd ; ~{: <br />..i I '. 7'. <br />- REQUIREMENT <br />I <br />. <br /> II 1 <br />-.. • , ~ "1 h ~ • ~ SAMPLE I - 1 1 .. .. <br />. - ,:I, ••E~ ~ - MEASUREMENT <br />. I. ~) PERMIT ~' ..? . {, "- ., _~ ~ n ~' <br />....... ~ ' ! <br />. , ~ - r .1 I. ~, ~ ~ REQUIREMENT `~ 'Y <br />~ ^ •~ T L Y ~ .. <br />.:. ~. '. 5 SAMPLE . ~ ` :~ ~.~ f ~.t 1) .. ..,.._ . <br />_ ;:~ MEASUREMENT <br />.. PERMIT : .~ k :+:~ .: ' -l ~: : ' .= L ^,: - .. r <br />. ~_I .; o '.. REQUIREMENT 7 .. ; ~. .. p ~ , ~.,. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF lAW THAT I NAVE PERSO <br />AM FAMILIM YNTN THE INFORMATION SUBMITTED H NALLY E%AMINED AND <br />EREIN; MD BASED ON TELEPHONE DATE <br /> <br />l ilCha Td A. I'.unFOA MY INQUIRY OF THOSE INOINDUAL9 IMMEDIATELY RESPONSIBLE FOR <br />OeTNNING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS <br />~ ~ I ~~ <br />aa <br />''1CQ f'I'C <br />I { <br />Sd TRUE, ACCVMTE MD COMRETE. I AM AWME THAT THERE ME <br />SIGNIFICMT PENN <br />TIES FOR SUBMITTING FKSE INFORMATION <br />INC <br />UD <br />G - 7 ~ ~ ~(~ ~ ~ E ,-, <br />`" ~ ~----- <br />, <br />F <br />ET - <br />, <br />L <br />IN <br />THE POSSIBILITY OF HNE AND IMPRISO <br />MENT <br />SEE IB U <br />C <br />0 <br />D <br />I (3%O 120. ZI 21 <br />J- ~ Gp <br />In <br />n 1 <br /> . <br />N <br />.S. <br />. ! 10 <br />1 M <br />37 <br />U <br />f 131 s <br />fPY <br />S <br />C <br />ld <br />w M <br />t <br />i <br />e <br />S <br />0 / <br />' BIONATURE OF PRINCN'AL EXECUTNE <br />TYPED OR PRINTED . <br />. <br />rr <br />. <br />. <br />r. u <br />a mnm. slsY <br />ars w ro <br />r <br />. <br />1 <br />,000 <br />sro ormuinlm Npn's+nlnte/brwNn emevrrhaW 6 rwa! , <br />OFFICER OR Al7TT10R12ED AGENT CODE NUMBER YEAR MO DAY <br />~pvmmcn I J wnM cnr~nnn nun yr nm vlv~n nuns Inarerenro en euernmsms oars/ <br />' _ <br />EPA Form 3320-t 108-851 Previous editions may be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.1 PAGE OF <br />