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~NMi'ffeE ngMrrquof235 Pnrrr E.rlmrMrrx.nw.V~NF..tl <br />NAME <br />..! i -. .. <br />ADDRESS ... 1 ; . ~ ~ ('.• <br />Iv <br />FACILfTY I i' • i i, .. r ' <br />i '. <br />LocAnoN ` ' <br />.,~ <br />NATIONAL POLLUTANT OISCNAROE ELIMINATION STafexi y:~'vCw, Forth AppravE. I. <br />DISCHARGE MONITORING REPORT D~ .. <br />2-!al 17-191 ~' -' ~ j ~: ~ Tom) ~ '^QRQB.No. 20g0-puVr <br />• r i .I ,: 4 c 1 ., r ! ~ ~ APProval a~Ll~rtsa OS-31-98 <br />PERMIT NUMBER DISCHARGE NUMBER (l ~ ) 1 <br />,.~ i <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY __ <br />FROM y - ; ! '~ ~ TO ~ a ~ ~ ~ l _ ~.:. .... .. .- I .. •: <br />no-2» n2-z31 rz~zsl rzsz7l rza-z91 r3o-3t1 NOTE: Read inatructlme befori canpletlnp thh fam. <br /> <br />~. <br />PARAMETER !3 4M onNl QUANTITY OR LOADING !s GN onlyl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE <br /> /4b53 5L511 !3B<51 I4G53 5I-s/ GF <br />l32-371 <br />AVERAGE <br />MA%IMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MA%IMUM <br />UNITS E% <br /> <br />Arz-eJl <br />ANAivsls <br />leF5B1 TYPE <br /> <br />l59-701 <br /> SAMPLE <br />:.. .. ~ ~ : - <br />~~~ <br />~ <br />MEASUREMENT ( );:) <br />! . <br />f L <br />r <br />. <br />. <br />- - -PERMIT 'i~.z>j?'•: <br />~ ` ~ . j - ..- -.- >•::g: "., ;t<~ ... 'it' i <br />~' . E~:~ <br /> REQUIREMENT ~ . ~ - , <br />\ T <br />>• _ <br /> SAMPLE <br /> MEASUREMENT <br /> ~~ PERMIT <br /> .REQUIREMENT ~ ~. ~ ~ ~ .~ <br /> SAMPLE <br /> MEASUREMENT / <br />P <br /> / ~r <br /> PERMIT ~ - ~ ~ .. <br /> REQUIREMENT. ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />i <br />NAMERTRE PRINCIPAL E%ECITTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF LAW THAT 1 NAVE PERSONALLY E%AMINED AND <br />MILIAR yATH THE INFORMATION SUBMITTED HEREIN; AND BASED ON ~ /~-' ~. ~ <br />' TELEPHONE DATE <br /> <br />IC <br />I a 1 <br />e ~%~ (` MY INQUIRY OF THOSE INDIUIOUAlS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION <br />I BELIEVE THE SUBMITTED INFORMATION IS /' <br />, <br />~ ; , <br />' , <br />TRUE, ACCURATE AND CQMPLETE. 1 AM AWARE THAT 7NERE AAF / <br />~ <br />/,j - <br /> <br />SIGNIFICANT PENNTIES FOP SUBMITTING FALSE INFORMATION. INCLUDING I <br />. ; <br />~ <br /> <br />~~ ~ ~ <br />THE POSSIBILITY OF nNE AND IMPRISONMENT. SEE if U.S.C. ! 1001 AND J] ~ <br />F tGte <br />/Prwl <br />tl <br />s <br />c <br />d <br />1 <br />1 <br />•F <br />n <br />o <br />0 <br />,/610NANRE SF PRINCIPAL E1(ECVIIVE _ <br />% 7 '~ ~ ~ <br />i y ~ <br />~ -~' <br />~~ <br /> . <br />. <br />. <br />. <br />.. I. <br />.r e <br />.Fr .arlm. m.r <br />x <br />MF <br />M, w ro a r <br />,00 <br />TYPED DR PRINTED re armvlrnun iRa.iaRnMrtr e/Mrrw sngnN.rgsLwa/ OFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />GVMM[IV FS ANU CAr'Lg1YA IIVI'1 Vr gl'1T v1vLq I Iurv7 IrteF/Tence NI erreCnmenn NTeI - <br />EPA Forlri 3326.7 (OB-961 PreViouB edidona "mey tis ulieE: - ' IREP CES EPA FORM T30 WHICH MAY NOT fiE USED.) -~ PAGE Of <br /> <br />