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,a ..r <br />PERMITTED NAME/ADDRESS peeL4 F'~wryNaw/la.nm dDlplnnp <br />NAME L Y !' ~.., .I •. ~ '•'~' (. r 7 / ^ . <br />ADDRESS ~ - - ~. F ~ ~ . ~ _ ~ 14 '. .I . <br /> <br /> <br />FACnrrv <br />LOCATION <br /> <br />NATIONAL POLLUTMT DISCNMOE ELIMINATION SYSTEM INPOfSI <br />DISCHARGE MONITORING REPORT (DMRJ <br />1-J6I 117-I91 <br />^l!1) 7 lU 7~'1 v <br />PERMIT NUMBER DISCNMGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM 'J J ':1 ' TO II ",` ~ '? <br />!16711 l11-131 114151 /16171 128-191 !36311 <br />Form Approved. <br />•- v T .. , . r ~ • •n r -.-TOMB No..2040-0004 <br />r ; „ I I ., - Approval expires OS-31-98 <br />,) l 1 <br />n _ r. tr <br />~~. <br />.. ': 'e •n ..tee-t+;111 OrC ~-•. ~. <br />. NOTE:, Read ImtruetlaDe beloro o I Istinp this f«m. <br />PARAMETER 13 Grd On/Yl QUANTITY OR LOADING !4 Grd On/Yl OUANTRY OR CONCENTRATION ND FREQUENCY SAMPLE <br /> !44531 154-6'11 !3B-151 !46531 15b611 <br />EX GF <br />T <br />l31-371 MALras YPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS lsa~e]7 !6.-e81 159-701 <br />i 0:'.`CT,~r. SAMPLE r.^-:r: 'Fr :"z:rt{::':~ :.•: t:.q:. .-t. ,: •:: r~ ( ~~) <br />t~ t• 1 j •~ t; u u ^, ~, T r MEASUREMENT <br />1!. _ 4 n PERMIT Ois ;: :k G{: .... ;4z?zX t Rt: D Fr1A* <br />F ryr:Lnzk^ <br />.. MD~vr• r <br />3LX F!tnh^ <br />'D.:. <br />_ (-,J"'~.yl~; 'I~"r'~4' REQUIREMENT ~ ~ ~ fg.Y~litr ~ ~ •P.~yr•T r <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT. . <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF UW THAT I HAVE PERSONALLY E%AMINED MD <br />AM FAMILIM WITH THE INFORMATION SVBMITTED HEREIN <br />MD BASED ON TELEPHONE DATE <br /> <br />f' <br />iC i'IA rd I'liil? ; <br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONLBLE FOR <br />OBTNNING TXE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION 19 ~^ '~ <br />/ ~ 'o <br />. <br />_ <br />}-I ! <br />i <br />I <br />l rlilC'Pr <br />nvir <br />- <br />r TRUE, ACCURATE MD COMPLETE. I AM AWME THAT THERE ME <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING ~ /1 l,~yr~..' ~~~~/ <br />- <br />< <br />nn;r. <br />: <br />, <br />: , <br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 19 U.S.C. E 10011MD ]] <br />f 1 ]10 <br />U <br />S <br />C <br />IMW <br />M <br />M <br />d <br />I <br />hW 6 _ <br />BIONATURE OF PRINCIPAL EXECUTNE <br />D7A <br />70_77 <br />~' <br />OO <br /> . <br />. <br />. <br />. <br />/ <br />. u <br />~I <br />wr .6AIb. rlrl <br />ne <br />11.. y ro S IO,000 <br />E <br />TYPED OR PRINTED rwn muirwnillpion~rf ola«wnemu,du rM6FrA1 OFFICER OR AUTNORI2ED AGENT CO <br />DE NUMBER YEAR MO DAY <br />IrVMML1V 1.l ANU CArLA1'IL I WIY Vr 1'11.1 YIVLn I rvnJ InslsanGO WI OUOGIIIIItlrIIO IItlItl/ <br />- ... ...~'.. ~1' ' T'. . t:T. - 7'.. ~° L:TL RLITY fl c•o. ~r v^co:r•,.u ~O.-, •~ <br />~ ~. .1 <br />n <br />^ <br />. <br />, .' <br />of •(rl'T-I~~ .. ,. rt ... , J' -'I. ;TA? rc°T~4LL7 'Tr`yT^ '?'o'r ^,+r ^TC , <br />r- <br />7;^4+l _ - <br />:q- <br />+r v ,: - <br />, v <br />^ • _ nna <br />^ <br />r <br />V <br />EPA F«m 3320-1 106-951 be used: ~ - <br />Previous editions mey IREPIACES EPA FOR T40 WHICH MAY NOT BE UBED.1 n ry ~ ~ t 7 n D ~ Il ~ ~ _ ? ,~ T ~ <br />- PAGE <br />^ OF <br /> <br />