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PERMITTEE NAME/ADDRESS!/nrlLdr NATIONAL POLLUTq NT °ISCHq RGE ELIMINATION SYSTEM (NPDES 1 ~ Ferilip Name/L osa(inn 1FdiXrrrnll ~1 P II / t DISCHARGE MONITORING REPORT r DMR) ,-.. om"' _ _ _ ~ ~ ~ • T^t'T p NAME _ ~. .C 6•/•IC F~Q I; IA1 (1]-191 I t t: - _ ADDRESS'i?V _ _ °L{ rf~.i--- --_ _.--_-___ .. ).~ .: n~• J (S"~? ':r) Form Approved. 1 )~1/ ~ ' 13 (' 'Y ~Y L N 2040-0004 OMB No p.(n ~,JY/p • PERMIT NUMBER ~ . FI A . _-_ w-cr, -~p3+r ~.va ^tv. O t ~-~-~:-;r ='/~ 4't7 LLL~~~~~~JJ h., NOR Approval expires 10-31-94 ------ -------- --- -------- MONIT G PERIOD FACILITT _ _ _ _ _ _ I ~~ fV - ~ "~ (A - - _ ~Lr 'r R YEAR MO ' DAY YEAR MO DAY 't~~ ~O DI -- ( '=a:. S~1{,O(;F I LOCATION ~ /C . 1 - - ~ ` V - - ~ - FROM ., i ~_ ' ~ • ~ ~ - - ~- ~- t f If r T R . 1 mow I J". ~, , ,, , ' . n •- ^ nn.~i l in.o;) !1t-•:I ! ~e-1n I )s X91 I )n-vn orm. his NOTE: Read instructions before completing ' (i Card Onlyl QUANTITY OR LOADING (4 C~a rd Onl c) QUALITY OR GONCEN RATION FPEDUENCV PARAMETER (Jb-c e/ !SJ-6/J (?S I51 iafiJil ~4-61/ NO. EX of SAMPLE TYPE (?~~)]/ ~ ANaLY515 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS :' ll. ':TATE° !a /1° h'.~• SAMPLE ...',t4.'.:." .. ..^ .t,..: ': [; 'r:4:;:+: it ..w •. ;.. •, f 2.) / :' t' r r O ' I' T MEASUREMENT ~ I DO D ' ~O (~ 1~ ) A A ~ i 5 •~ ~ ~ I a #~>an>b ~' a .',` . O itT F1~ 'k:: (: !jrt it 1Jr~t Qth •jt~ n * • S 3y, it: fi .. PEP.MIT . .. ~I): •tT ~{'1SS YAL^.. REQUIREMENT .. u`f,:'} .~•, ~A.LO~ ./.n -r r.^~Tr r X51{? q;'I) SAMPLE .r.~'.y'~3 ;y ,:, ...Y~ 'erv s}•!~: '. ~. Y... i.h.' ( ~~~ / ~ • • 'M1 N 1 MEASUREMENT 'OQ t/ 1 jf7 K I . , S _ ~~': L. (; y n .. >)[. %Y rib : ' L'Ps+ IF77101ditd ~S CIIRfi[:=t :'~_ 'TREY qAn PERMIT A c r. l~ "~ s<''s .: it7 rj j y L 'I ~: REQUIREMENT - b s K ri i ALOE - . SAMPLE MEASUREMENT PERMIT ~ ~'{~,: REQUIREMENT ' SAMPLE MEASUREMENT ' PERMIT ~ ' REQUIREMENT `.i4 SAMPLE MEASUREMENT PERMIT REQUIREMENT ' SAMPLE MEASUREMENT PERMIT REQUIREMENT ~ ' SAMPLE MEASUREMENT PERMIT ,- REQUIREMENT NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERnFV urvDER PENALTY OF LAw THAT I HAVE PERSONALLY ExgnnNEp TELEPHONE D A T E AND PM FAMILI4R WITH THE INFORMATION SUBMITTED HEREIN ANp B45Ep L, hL Y Y LI A ON MY INOUIRV OF THOSE INpIVIpUPLS IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION IS /~ • ~ O r ~ \ 1 TRrIE ACCURATE AND COMPLETE I AM AWAPE THAT THEFE ARE T N I K e ~~II I C h h q r IO SIGNIFICANT PENPLTIES FOR SUBMITTING FALSE INFORMA NCLUDING THE POSSeNrv OF FINE AND IMPRISONMENT SEE IB uBC § fool AND GN(~.TUR OF PRINCIPAL E%EC TIVE C/I l O C OI ~ ..t71~ rJI L Q t 1 O ~ 0 J C TYPED OR PRINTED "3 use 5 1319 (PrnaOin antler tllne vumrcs n' ncludr (mrs up la f100(N) ~W nr mnlmum ImOruonmrnr N hrrvern fi momhe uW i snrsr OFFICER OR AUTHORIZED AGENT AREA DO NUMBER YEAR MO DAY COMMENT AND E%PLANATION OF ANY VIOLATIONS (Kel[IrnrC all L!JCnlnenl5 nelPl '": 7T T. 1.~,^) F^~ t,Fr•.ILS OF TES?' fnn~r-,nnc, o "lF. !C50 - S?4TIr•~wlr-,,~ n.~T~;•r' ... f. ...c (. r: .- "' '•4L T'~ 5.0; ')F T°-T .~RGANI`_"!`;. ABA AT^Af" dr'UrF. TOXICITY T°S'" RF,P~RT ?O4° Tf) '1%°. r`1PI°.S OF eS,L Cn M c r EPA Forrn 9320-~1 jRev.9rf181 Previous a IrlOrl$ lrley fJe used. (REPLACES EPA FORM T-40 WRICH MAY NOT BE USED.1 00057/950623-1743 PAGE 1 of !~ d ..