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PERMIT'IEE NAME/ADDRESS /7M.4 F,srary NaWLoc,nw I/D/pi.a0 <br />NAME (: t ~'. . r v r ~. - r , . , .. .. .O ~ <br /> <br /> <br /> <br /> <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISLNMOE ELIMINATION SYSTEM INPDESI <br />DISCHARGE MONITORING REPORT IDMRI <br />17-161 17-191 <br />PERMIT NUMBER - DISCNMGE NULteER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM 9 '1 ~ 1 "' 1 TO ^ r n 3 ++ <br />/7Q711 /77-131 /14151 /I5-771 179-791 13Q311 <br />. n ry ,- R„ F- ~ ,- n ,, .r <br />(^_ ,T -) <br />1 _ <br />Form Approved. <br />~+.OM81No..2040-0004_ . <br />Approve' expires OS-31-98 <br />.NOTE: Resd IDYtructiarr balorY eomplstlnp thiY form. <br />PARAMETER !3 Grd OnlYl QUANTITY OR LOADING !/ Grd Ontyl QUANTITY OR CONCENTRATION NG FREQUENCY SAMPLE <br /> 146-531 154611 l38a51 le653 !5461/ EX of <br />l32-371 <br />MMYSIS TYPE <br /> AVERAGE MAXIMUM UNITS , MINIMUM. AVERAG MAXIMUM UNITS nt7-sal (54581 169-701 <br />".l'..r.t:s"i °?-ar SAMPLE 'A'c3'~x: rkr.~~,; ...,......•: r F <br />( ] ~) <br />~ <br />r <br />;. ~~CC''r t:'.1 -iL~. MEASUREMENT , O (~ <br />I1_~~ 1 'I PERMIT att:S/Arxry ;;¢rtrs.~Xt. =:~ <br />' ~;Y:tr•?'''r>•' ~,1 ^"^ft?r IK~1'~ .Erne. <br />. <br />i~'1',1. '- VA 1.'Ic REQUIREMENT r.`-r-. ~ ~tT^.R ~R 4.- hRTiv ry ar•/I r?`tTy <br />~. L,_. ~ ,, ~.,, .,n+. nr <br />- ~ <br />" SAMPLE <br />MEASUREMENT ( 73) ~"-Frr:# it:^,~~t.A 'r <br />C~/t, ,,. ~• <br />O <br />~ <br />/ <br />~ <br />_ <br />i t„ t , ,i <br />PLAai / ~ <br />..,/L'.U 1 G .'? :PERMIT 9c{'J?P : .~Rf,PAR~! .~tt.,Sr;E>`k ~cr4t<^ ~ >~tA~4rt<.:1 '.R•'.:Y!: r ~.NL`F/.. .~Al.:'r.. <br />I:FF['J?"'C f ll^ YRLUF 'REQUIREMENT 3(S~0. .O V DATLY ~X' !1GJ ~'.t•'. <br />MAN N <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. <br /> ~REQUIREMENT~ <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cERnFr uF1DER PENUr GF <br />AM FAMILIM WITN THE INFO uw TNAT I NAVE PERSONALLY EllAMINED AND <br />RMATION SUBMITTED NEREIN; AND BASED ON TELEPHONE DATE <br /> MY INQUIRY OF TNOSE INDIVIDUALS IMMEDIATELY RESPONSIB <br />E F <br />R <br />1 <br />!ZIC{• <br />rd <br />!!! L <br />O <br />IEVE T~S <br />~ <br />NI <br />F <br />A <br />I <br />ET ~1 <br />/ <br /> <br />18 <br />1 <br />: <br />S <br />RUE. <br />A000MTE <br />AND <br />CONIPLETE. <br />AWME <br />N <br />AT THERE ME , <br />, <br />~ <br />~ <br /> SIONIFILMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING // <br />~ <br />EnVlronrvent~! ~,1Drrl1:•er , <br />THE POSSIBILITY OF RNE MD IMPIIISONMENT <br />SEE 16 U <br />S <br />C <br />1 1001 MD JJ - <br />.. <br />~ . <br />. <br />. <br />. <br />1 13ta <br />U <br />S <br />C <br />/A <br />W~M <br />W <br />5 <br />i <br />A <br />d <br />/ <br />5 BIONATURE OF PRINCIPAL E%ECUTNE 4 Q- T a R ~ <br /> <br />TYPED OR PRINTED . <br />. <br />. <br />. <br />rr <br />, u <br />r e <br />,r mnm, nl,E <br />K <br />. <br />, <br />.+, y ro <br />10,000 <br />Y.ennrr:m.n inAVbvmlvrr or aN..«r srr.aree,.,s sYw..l <br />OFFICER OR AUTNORI2ED AOENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAV <br />GVMMCN IS ANU CAPLANAIIVI'1 Vt'AnT VWL/.IIVIYA I/.We/YOGI N/IILeC//TBnLe Oe/I/ <br />. ...-3": 3~/-~" .1 •~T^S_ ^L-, yr11•I .r~I.' Y!'^'!YL +r.•^pv•. _/, y...~ nv .7T ...•ct -~r..... y, ~]7. ~ <br />!i: ~, c'i..~. ~C;.Li. .- ._ ~ ~•,~ 0~11'r ti /Jit ~. `!'t ~.)U7,'. ['1,'l~i". "`' ~'1~OTT+: r7 ~[~crr:"- . .] ~~ r,' <br />r <br />EPA Form 3320-1 (08.961 Previous editions may be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.) ~ ~ ~ / q / 9 ^ (` ll ~ -1 _ ~ C' l n PAGE t OF <br />