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PERMITTEE N.4M~/ADDRESS !!nrlude Fa[iliry Name/Loralion i! di?erenll NAME-~a1~__~I _a._~.~1: 1_~I~_~_~1-..-_-- ADDRESS _~~',r ,, _~~_________ ---'i'ce°-d~JL -``--- ------- FACILITY LOCATION ------------ ------- I f.1... C ", ~ .-. - NATIONAL POLLUTANT OISCNARGE ELIMINATION 5\'SiEM (NPDES ) DISCHARGE MONITORING REPORT ! DM11R1 (1-161 (I7-191 _ ~I: r:. (~_.~. PERMIT NUMBER MONITORING PERIOD YEAR MO DAY YEAR MO DAY FROM ~L TO /- ~I ~I r1n.nl r>o-rl na-/il ,~e.nl ne-+ol ,:n-111 ` ~; _ ~ ~' Form Approved. _ -- ~ - OMB No. 2040-0004 ~ ~ ~ ,. _. ~pgroval e~Ptres_70131-94 . ~U ) ~ \ ~ - NOTE: Read instructions before comDletinD this form. (1 Card Only) QUANTITY OR LOADING r1 QUALITY OR CONCENTRATION (4 Card Onl PARAMETER (4D- )) jJ 6IJ , i i p JS 4J 54 46 ryp FREO~NCY SAMPLE ( - ) / ) ( - - /) ( - . EX TYPE (N 97) gNgLrss AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS 1 F9 ~ 16: b. ) (6Jt~d) f - a/ .. SAMPLE ~ :'r'i. .:_ / ~~ MEASUREMENT ,. .. I. , PERMIT .:;7: - .... ° r. ,... • ~ ' . r •• ~~ t ~ )j 1 ~ t RWUIREMENT- ___ - - - -- _ __ 1 [; , i. ... .... l .. ,. . T ~.J !. .. ', ~ - SAMPLE 'c:ci:,[~. .. ..:-.~.:." MEASUREMENT r c l . a J ~' PERMIT ... ~ I:.-. ' -.3. - .. •' I ", r ~ J J • REQUIREMENT +.... ., - ~ 1 _ J _ .. .J r r I SAMPLE MEASUREMENT ... , PERMIT .'~": i `i ..t.; i. :r. ~ 7 . . ~ ~ ~ I REQUIREMENT ,, ,- _ , /, . , J ~ ti .- ',, _ ~ ~ .I. '.. J SAMPLE I \'.]~ :: r,.f..;: r,: ,: :;-i:i:i ::: ''i: ` ~ - . L MEASUREMENT "~ . .. PERMIT _ - ~ .: s ~ ~ ~ ,. '; as; .. I, ~ , - ~ ~' r ~ - • REQUIREMENT - _ _ _ . '[ .: r.. ~~ , . rL SAMPLE .-. - ~ .. ; ;T . r- J ~.' ,, MEASUREMENT . ~ .- ~ ,/ PERMIT ~ .-, ~ ~.q. :'.: .. .. I: ~. .... ~ ~ ~. l _ .,\ I. REQUIREMENT ~ , -~ i J J. ~ -. l._ ~ .~ _ SAMPLE ::::i'. ~ . . . ~'. s I 1 \ , r ai~.~ . iL•I. ~ ...i:. . MEASUREMENT l_ ., .. 1. ~I.- -. • :• I r. PERMIT .: ... ~~ .1 ':r-:. ~ (: ;t'. ,. .. r / - L _ r. .t . r~ ,~~ 7i- REQUIREMENT _ _ _ .~ SAMPLE MEASUREMENT PERMIT REQUIREMENT NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENgLTY of Lqw THgT I HAVE PERSONquv Ex AMINED AN MI IAR W T T RM TELEPHONE D A T E p qM FA L I H HE INFO ATION SUBMITTED HEREIN: ANO BASED ON MY INQUIRY OF THOSE INOIViOUgLS IMMEDIATELY RESPON9RLE FOR OBTgINiNG THE INFORMATION I BELIEVE TM1E 3flBMiTTEO INF9RMATIOV IS TRUE gCCURATE 4ND COMPLETE I AM gWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMPTION INCLUDING L/.~'^ a///~``~~~. /7 THE Rosslaiurv OF FINE AND IMRRI$ONMENT sEE IB GC § Idol I /o Q/_L1,7~o rG /~ , v r Z ~ grvD U 33 UBC 4 1319 (Pcvlli[s uWrr these namrrs mv ' n[lude l,n[s u m SIGNATURE OF PRINCIPAL EXECUTIVE I V TYPED OR PRINTED _ p SINPOn aW nr ma vmum rmnnsmmrnr ur beu'een 6 months aW! years / OFFICER OR AUTHORIZED AGENT AREA` NUMBER YEAR MO DAY CODE COMMENT AND EXPLANATION OF ANY VIOLATIONS (RCl[RlIrP all allarlimenls n[r[/ EPA Form 3320-1 (RBV. 9-B8) PreVlOUS edi(10r1S may be Used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF I ~ ~_ i I ~ .