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PERMITTEE NAME/ADDRESS lInirLirWryNana/Lxurm UDrSfrnnq <br />NAME .. .... ..... .... ~.. .... .. - ^ ' . <br />ADDRESRS; IY» lr /' - .ifl I~ "> - -~: ,. I'i <br />- ' l - <br />.. -','~r , ... ~~ .. .,. ~. T. ~. <br />,,, -... ~J 7'.S5 <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTMT DISCHMDE ELIMINATON SYSTEM INPDESI <br />DISCHARGE MONITORING REPORT IDMRI <br />l7-161 l17-191 <br />., .. Ci 1~'Ji'1 ,'. ~ <br />PERMIT NUMBER DISCHMDE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAV YEAR MO DAY <br />FROM ~ : _ TO 1 <br />nn>n nv>or Hutt UA>71 /7R-091 130-3II <br />Form Approved. <br />.-. ..- .. -. - ..- OM&Nm 2040-0004:• <br />rr _ , Approve{e~plres 05-31-98 <br />- P ~ <br />. T,. , <br />j NOTE: Read InstrucUoru bslors aompktinp this form. <br />PARAMETER !3 Grd Onlyl QUANTITY OR LOADING 14 Grd On/Yl QUANTITY OR CONCENTRATION ND. FREQUENCY SAMPLE <br /> l46-531 !54611 138J51 !4653 1546/1 EX Y95 TYPE <br />l32-371 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (61~6J MAL <br />!5J-1r81 (69701 <br />~ .cJ'~ SAMPLE :. {: r: -:nr~ {:a,,. r. •:., :~=:, ~:~r: ~ e~G~p <br />°` 1J r <br />,y <br />O //'.~ <br />~~~ <br />iU~ '• L .:-:f ~: 'v' ~'^. ^I ' MEASUREMENT rj /=//w O.'7 ~ /~O 9 <br /> <br />JJrc U ,. f. <br />PERMIT <br />>r':...r ;;,y ,`-. <br />:, iFK.r# . <br />,,, ...y ... 4 A ._ <br />', s't <br />^'~ ^C'k•r <br />any, •~~ <br />:P,R Sa <br />~F'LU;:17 rc ^'.I, ~REQUIREMEN7 ~ .•,. ~ yr)•.,* „r- n.bT T' ~v r;/T x-1•'a <br />-i Y•.'~i :i'J ''!°" _ I,T'r SAMPLE ^C(=.'.'.'Cn;: R': ,-. :w': 1='`''a' <br />~O~J' <br />Q ^^~~ <br />~ <br />~~ { l91 <br />~ 1 <br />` ~V <br />~~ad <br />)I.;SJL'I% i MEASUREMENT r Q. <br />LJ7 <br />)~.i?4 l G ;1 PERMIT r:;;r,:=~:: ,~;:^':r.-;; .. .. -. „r,..~ 9'PQrm n''np~^. , . .-~~ ">' <br />_ .f~. •• ;r•~ <br />:F;~ <br />. REQUIREMENT -fit r: ~~r a Ev^ ^n~~~t *r Y•r .,•~T •• <br />., ,'; <br />_ <br />. <br />i, .. r <br />.: J.'f.:•:,~ o-i'r •. r_.ILL" SAMPLE -.':ri: ;: ,.^~: C=~'" ... :::... <br />Op I <br />O <br />O~Z <br />Q { ~O) <br />~ <br />3~O <br />G~Ag <br />dl~=r.OLT'. ~ MEASUREMENT , • <br />C ., <br />ill6 ' <br />~' PERMIT "c;c;:;L „L ,^, $(:*:r,: qt , t: ~::: w.°~:':w,. ~: nen77 nit ;1~~-.~ .w .T~ <br />_ <br />. . <br />:IU ,".+'i ,'7`'4 l.; L.._ REQUIREMENT 3lTn~ Ivf' .., <br />;ytiTY_§ -rL ;)t: .~.. <br />"t <br />~~~, i; /1 '{.._ :~ .. .:' SAMPLE ,`. t: :t=. .:+,.._.Y fi'`'t' Qr22 p <br />0.3-1 ^, ~ C <br />5 .~t2A 13 <br />.,•>-~V;p f,:,T,; MEASUREMENT <br />l_i?3 Y C PERMIT ,=. .,t:;. `.<G:~F¢f: :i t ;:f .. .fir';: ':1` .r~fj -.... ^r C,.'.. »TV . <br />i'L'J~`'i 'i^'I» 'T„L' REQUIREMENT 'a CF znnb 'r/r, bTw '+v ^_ /• <br />'y')e, r,. ~7" ;.'TI O.' <br />~ SAMPLE 'A 1' <br />~ZOL) <br />^ q {L.~~ <br />~IIaZZ"l ( ]~} ~ at,;.': •; ~.;. .. .. o•. V" ~ <br />Q '~ <br />~ <br />~ <br />/ <br />INS.'fAf` <br />I3~ :.T~ ".- n. <br />_::C MEASUREMENT 11 . <br />J <br />7 (i 11~V 1 ! PERMIT r: cat/J'•i .~. ;T ~. i :t:...~.,... .a.'Ir. v: i,-:; y ' T•5 •.rN' - t' <br />~i 'T.[!~' ~ {,='~~r; q L- REQUIREMENT 31!U.l ,1NG 7SI:~'{ :". .{ ;) <br /> <br />)i.. 3..0 ~ - <br />SAMPLE <br />.-:: r•4.`•C: <br />O <br />( : l ~ <br />Yuy.,..:.._ <br />:;~,,...y:. ~. <br />.. ~ <br />0 ~7T2// <br />T/ <br />V IiVAL <br /> <br />r ~ L' S L <br />MEASUREMENT ~~ <br />. <br />'4;a5 1. C ~ PERMIT. .`-r; ~ v •~_1 ~:'arr ,.,` ::,-,"~^,. ~- ., .-' ~~.'.,Y '0' <br />i` T. L' ~ ', ! ' S _ -] - REQUIREMENT ~ L. Fl R " .1 .'. S •. r,c ~ ~• •. •~ r- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> ~REQUIREMENT~ <br />NAME/TRLE PRINCIPAL EXECUTNE OFFICER I cEnn Fr UNDER PENUTY QP uw THAT I NAVE PERSONALLr ExAMINED MD <br />MD BASED ON <br />BMITTED HEREIN <br />T <br />O TELEPHONE DATE <br />~I : <br />I <br />N SU <br />AM FAMILIM WITH THE INFORMA <br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONABLE FOR <br />BMITTED INFORMATION IS <br />E S <br />:ich ll'd I'4IIIei U <br />OBTNNING THE INFORMATION, I eELEVE TH <br />AT THERE ME <br />E T <br />~ <br /> H <br />TRUE, ACCURATE MD COMPLETE. I /1A1 AWM <br />F <br />RMATION <br />INCLUDING '~ ~'~ 0 O <br />E:~vironrentu{ ~1Ji'1r'T ^C , <br />O <br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE IN ~]C /Q-~7~i S ~ I i~ <br />' <br /> THE POSSIBILITY OF RNE MD IM%BSONMENT. SEE 18 U.S.C. t 1001 MD as 610NATURE OF PRINCIPAL EXECUTNE <br /> S.C. 1 rate. Igweh. I.Mw drr Aervroa ,,,.r iNII.Ctr rvws ~ ro 710,000 <br />U AREA <br />TYPED OR PRINTED . <br />.rW Ormuin.n Yrevr/sa•.rl.nrWNfwwn6marU. rH6reva/ OFFICER OR AUTHOR12E0 AGENT CODE NUMBER YEAR MO DAV <br />r <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rs/erenee e// sttsenments Hare/ <br />1 L_ ~ .. 1. _ .. ~~^ 1 J .. _~ i .. - g l~ T r 5 { L T C F' E~ [ P r .. 1" T~ r T' ~ o T -' n~ ~ 7 i_ - -. I ...- -, <br />_~~.1 'l• - r•.9r ii. 1. 'J In' .'11 Jt) ] nr`~n . ~ .t • ^TL , _._~ T "'Tl rl •C,~ ~/, Jr; -. <br />EPA Form 3320.1 (08.95) Previous editions may be used. ~ (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.) ,. ~ ~ T ~ 7 _ _ ;, _ _ ., PAGE _ OF <br />