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EA~:1't' 14 ~ r ~DJ}' 9~ JIniJu•.F <br />Fari/iry' A'ame/Loraliml if dilfereml <br />NAME _ .. . <br />-_-L•711r ti-a~_!~------------- <br />---._,~_---------- r~ .__~_ ~-- <br />FACILITY <br />LOCATION ___________________ <br />- r .r, _ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPUtS) <br />DISCHARGE MONITORING REPORT ! Oh1R) <br />(?JF1 (17191 <br />,.~ Form Approved. <br />PERMIT NUMBER _ _ OMB NO. 2040-0004 <br />MONITORING PERIODcL I ( ,ApPfOVal expirG$,1D~3.~-94 ., <br />YEAR MO DAY YEAR MO DAY <br />FROM - ~ ~~ TO . r.. ...~. 1• ~-- .. I 1 i:i1=: <br />!gin-nl !n-oll rla.+c. ne_nl nx_+o. .m.xil -NOTE: Read instructions 6efD e'CfSfiDletinQ this lDrm. <br /> (J Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br />PARAMETER (46 -5 i1 (J4-611 !?8-45) <br />SJ <br />46 <br />?4 <br />6/ NO FRFO <br />UF NCV SAMPLE <br /> ( <br />J ( <br />- <br />- <br />) , O <br />(i7-17) EX ANALTSIS TYPE <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> Ip14J) 164fi{I 169-]01 <br /> SAMPLE .. ... ~ ~ <br /> <br />MEASUREMENT M <br />I -1~ 1. ~ PERMIT <br />~ ':rv <br />~ <br />~ <br />~ ~ ' <br />~~ ~ <br />I <br />~ (• , <br /> REQUIREMENT <br />.a .. ~ <br />_ .._ ._ <br />L~' <br />u. SAMPLE f:'J': ...R' ~t?:.`[:.:f. c - <br />~ <br />. <br />_. <br />. <br />MEASUREMENT ~ <br />.~ <br />..I C}.. ~ . .I PERMIT :~:-l:`(v•. ~~ ~ <br />- I ~ -~ <br />_ I. . REQUIREMENT ' <br />i <br />J.. ~ 1. D ..IU Q SAMPLE ; ~~ i~i~.'. .: . -. 'Y',--~-[:: ' <br /> MEASUREMENT <br />L 1.. <br />~ <br />. :_ I. . ~ PERMIT ~ - _ . <br />_ 1. 1, - rT ~ REQUIREMENT T 1 ~ . , <br />,il.: ~ .( ~ ... SAMPLE r : l..'' - .~ <br /> MEASUREMENT <br />/~. ~ 'ice I <br />7 ~ ~ ~ PERMIT .. ... <br />~ <br />~ <br />_ REQUIREMENT "' ' <br />1 ~ I ; <br />~L~ ... I :~ SAMPLE f:c':.-i•.: ; 1 :.f.:i:': .. Y: '. ~..:. r. ~. <br />- MEASUREMEN- ~ <br />~ - .. 1 . <br /> <br /> <br />-. <br />, ., 1. _. ~ PERMIT <br />.... <br />.. .1 <br /> <br />. - <br /> <br />.. <br />.. il.., 1. ./ - <br />I ~ <br />.. <br />_ _ <br />. REQUIREMENT _ J . <br />) <br />., , <br />, _ _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERnFV UNDER PENALTY of LAW THAT I HAVE PERSONqur ExAMwED <br />' TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATIQ <br />J SUBMITTED HEREIN AND BASED <br /> ON MV INOLIIRT OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> 06TAINING THE INFORMATIOrv I BELIEVE THE SUBMITTED WFORMATION IS <br /> TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE <br /> <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE MFORAIATION INCLUDING <br />THE POSGIBIUTV of FwE AND IMRRISONMENT SEE IR <br />S <br />C <br />4 ^ <br />~~t! ~~ 7s~ <br />%V <br />~ <br />O~ <br />/~ <br /> lool AND <br />u <br />. <br />. <br />33 U <br />SC 4 1319 (P[nallin unJ[! IM1[Sf il0lul6 mJy nt'IuE[ Im[5 uy ro SIGNATURE OF PRINCIPAL E%ECUTIVE <br />~ TYPED OR PRINTED . <br />SIO.OJO anJ nr mJximum ~mpnsrnmem ai brrueen A months anJ ! Imu.l OFFICER OR AUTHORIZED AGENT A NUMBER YEAR MO DAY <br /> COD <br />COMMENT AND EXPLANATION Oh ANT vlVLq nVNS (K[I[([nC[ all a!ldrnm[nls octet <br />EPA Form 3320-1 (ReV. J-BB) P(EVIOIIS Edi110115 lnay bQ USBd. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 _ PAGE OF <br />.. ) ~ 1 - . <br />