|
PERMITTEE NAME/ADDRESS l1rY4irdryNsWLrerlon UDr~inu)
<br />NAME . - ~~ -
<br />,.~, ._ _, L .~
<br />ADDRESS l: C - u ~. ~ ~ ~ ~ ). _ .. _~
<br />~o to ~~~...!JO
<br />FACILITY •. ` 1 ` ~ _ ,. ', ~ o
<br />:.,
<br />LOCATION
<br />NATIONAL POLLUTANT DISCNMOE ELIMINATON 9YBTEM INPOESI
<br />DISCNARGE MONITORING REPORT IDMRI
<br />r7-16~ n-T81
<br />PERMIT NUMBER DIBCHAROE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM ~ ; ~t, ~ I, TO ,; - u,, ~ 1
<br />/76711 /77-]31 1]4751 /]e-]71 UA-991 /9Q.?fl
<br />Form Approved.
<br />_ , OMB No.-2040-0004 .,
<br />,. .. ',
<br />:II _~ `) Approvellezplres~05-31-98
<br />T., -
<br />. ,.
<br />,. NOTE: Raed instruetlons belore complatinp this corm.
<br />PARAMETER 13 Grd On/rl QUANTITY OR LOADING !~ Grd OnlYI QUANTITY OR CONCENTRATION NQ FAEOUENCY SAMPLE
<br /> 14653/ /54611 138-65/ (4653 15461) of
<br />137-37/ EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS e3
<br />61
<br /> 1
<br />-
<br />1 !64681 /6&701
<br />!;; SAMPLE ..
<br /> MEASUREMENT ~ ~ ~ -
<br />..Uall,! .. ~ - PERMIT . .:,ci .:: .. . . . ,. "T
<br />o ~..
<br />'•
<br />l~
<br />'
<br />'
<br />'
<br />i
<br />_
<br />..J... .od T REQUIREMENT ~ .
<br />__ L. o
<br />~ ltf'
<br />
<br />• ,
<br />,~ . 1
<br />=.•1 DSF r... L- ,I~' SAMPLE .. .' ~f '+:-.• t
<br />~r
<br />r
<br /> MEASUREMENT ~
<br />u V ~ S ~ Z U `, PERMIT :. ,. .-,, ,. .. ~:...:. ... .... ,. ,.: ti.
<br />l •C •Jr
<br />,
<br />.J.. .. f REQUIREMENT ,.,,, 1: p', .'
<br />. / -
<br />~ ' «,
<br />Jam:. ., :0 _.._ ~ SAMPLE ..., :r;. ... r,- ~{- - ,:,•
<br /> MEASUREMENT
<br />J3~dl _ v ] PERMIT .. •. ••,• ~ ••-_..- .. ,.;.:.., .. _ _
<br />'
<br />~
<br />:
<br />: ~ :
<br />:
<br />U
<br />i i REQUIREMENT ~ :;::}iv r
<br />'' _
<br />,
<br />.
<br />I
<br />.L
<br />L
<br />~.
<br />r i i:~S ^ :
<br />.'i, 7.'
<br />S .
<br />:'T ~i SAMPLE S Q? - - -
<br />a
<br />,
<br />..
<br />;,~
<br />MEASUREMENT ) .
<br />.,,.. .. , ..
<br />..
<br />~. ~.`~ I PERMIT OY~~:.:::"~~. [. „-L'iC.? ,.:.;, .r:. ;:
<br />.., r ::-??=>: ':
<br />,.-. .-.
<br />~
<br />/ ,rl.
<br />..L~, ~~ REQUIREMENT 'Q. -. 'i'; L aL~ .;: ~D
<br />-.. SAMPLE r': 'r :;:. .,. .. r. .. ..
<br />J; ~
<br />J MEASUREMENT -
<br />e < ~
<br />~/ ~: .'
<br />) ~ PERMI7~ is :::c ?c .± ;:i<~::; 1't :<
<br />. .; ,.:.;... ...
<br />.• .-
<br />
<br />i
<br />' _ - .. ,
<br />-
<br />.. 1 ~ : - J i -
<br />
<br />~,
<br />-
<br />REQUIREMENT
<br />~
<br />
<br />
<br />. ~.~ . yr 1~1
<br />;-
<br />.
<br />~ ~-I'i
<br />• 7 .
<br />.
<br />.::.5 t~ " a.- .: SAMPLE :: ': ~: :~F'; , -, ... .., ,
<br />:.
<br />1. ~ ~~ 1 MEASUREMENT .
<br />-
<br />,
<br />'I':., rb .. I PEAMIT 1..~;-;: :;: .iL. .~
<br />~ ~ ~ i=_ .. :
<br />~ ~ ..:rt:~
<br />- -
<br />:-
<br />~ I ~'
<br />f
<br />J J
<br />'
<br />J o' 'REQUIREMENT . _ r- . - :•. i. .
<br />.
<br />. _
<br />. J - 4
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERM17
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FA FY UNDER PENAl7Y OF LAW TNAT I HAVE PERSONALLY EXAMINED AND
<br />MILIAR WITH THE INFORMATION SUBMITTED NEREIN
<br />AND BARED OM TELEPHONE DATE
<br />/ ;
<br />MY INQUIRY OF THOSE INDINDUKG IMMEDIATELY REBPON9BLE FOR
<br />1
<br />~!:
<br />'
<br />~ OBTNNING THE INFORMATION, I BELIEVE THE BUBMITTED INFORMATION IB
<br />~
<br />-- TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE
<br />- SIGNIFCANT PENALTIES FOR BUBMITTING FALSE INFORMATION
<br />INCLUDING
<br />- t ~ / ,
<br />THE POSSIBWTY OF RNE AND IMPRISONMENT. SEE le U.S.C. 1 1001 AND ]]
<br />SIGN ~/ / ~ ~~ " ~
<br />' ~ - . "
<br /> u.s.e. 1 tGts. rPrrnY.. ulwr a.r mltm. rear /rAw r.:.. Ip ro tlG,Gav ATURE OF PRINCIPAL EXECUTIVE •
<br />
<br />TYPED OR PRINTED
<br />rN rmMH:vn lrnt+/AO+mrrrrWNtwrn smme)s rW 6 NNVa/
<br />OFFICER OR AUTHORIZED AGENT
<br />D
<br />NUMBER YEAR MO DAV
<br /> CO
<br />E
<br />L-l .. '?~ .. - .. .
<br />EPA Form 3320-T 108-951 Previous editions mey be used. IREPLACE6 EPA FORM T-40 WHICH MAY NOT BE USED.) ~„ PAGE , OF
<br />
|