Laserfiche WebLink
PERMITTEE NAME/ADDRESS /Include <br />Fafilill' Name/Lncalion i( di(@rrnll <br />NAME ~ 1~,~ _~-:~.'i-......~ <br />ADDRE55_.~~2.~_Z•____-----_---- <br />FACILITY _ <br />LOCATION____________________ <br />NATIONAL POLLUTANT OISCMARGE ELIMIN ATIOH SYSTEM I NPDES) <br />DISCHARGE MONITORING REPORT l DA1Rl <br />I_'-Ib) ll7-I4J '_ <br />^r ;~I •' ~ .. _J Form AQgroved. <br />PERMIT NUMBER - ~ T' - - OMB NO. 2040-0004 <br />~ - ~ . ~ -, ApprovalJgypires-10131-94 ~ - <br />MONITORING PERIOD ' <br />YEAR MO DAY YEAR MO DAY I J <br />FROM _ TO 1) .~.: •:'.-~ .C J L.i~.. / I .;:. <br />rzo-'r I . ~!-zn 11Ja51 r'A-nl . ~x-rvl r .o-?I I NOTE: Read instructions before completing this form. <br /> (? Card Onlr) QUANTITY OR LOADING (4 Cn rd OnIJ') QUALITY OR CONCENTRATION <br /> <br />PARAMETER <br />(JA-5)) (iJ-All <br />f78-45) /JA-5.7) (54-61) <br />NO' <br />EX FREQUENCY <br />of <br />SAMPLE <br />TYPE <br />( 7?-171 AN4LV 515 <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA %IMUM UNITS ) <br />EJ I <br />] <br /> r <br />l <br />O IAJdtlI IA9- <br />U <br /> SAMPLE .'; ;t', i::.:f :.:i::: ~ ~ ~ T~ <br /> MEASUREMENT <br /> <br />r <br />~.);J.1 _ O ~ PEP.MIT ... ...< <br /> <br />... <br /> <br />.... ,..,.r :. : <br />_ r <br /> <br />.:.:.: •~ ~ -•t~"-• t'• .I; 1J <br />i 11 <br />~ <br />• ~.i <br />~ REQUIREMENT (c <br />=';:°~ " <br />- . <br />. . <br />~ t . <br />0 <br />1 <br />J . ! y` <br />.JL1 i..a .. .. _.. l'-iL SAMPLE .:'n, .'. Y: -._t ~.?-,r` ~ , li <br /> MEASUREMENT <br />. - ~ ~ PERMIT ~ ,. .. J. ~ I - • t^ I . <br />- REQUIREMENT <br /> <br />-'.L ) )r. ._aiL SAMPLE :; o;: ~:i: v': .. i':;:' ,.:}f,:'. / 'I ?~ <br /> MEASUREMENT <br />/ ~ = v ~ ~ J PERMIT - ~ ~ - I~- •' ~ - '01" "-~"~ T ~. <br />.U S ~ ~~ L _- REQUIREMENT _ ,. ] , - <br />.J.l/ L ~7 ~_ .. ~~ SAMPLE / :~ <br />: ilr ::!t::. .... - <br /> <br />. ,. .._ PL: .. MEASUREMENT <br />-~'. r ., _ PERMIT 'u. ~.. ..-, r / <br />; _ . <br />. ,. 1- 'Sl :r-.J.._ <br />- REQUIREMENT ~. ~ , <br />I _, <br />1 <br />s. SAMPLE .•.. L.:'. -• ~ r ( _ <br /> MEASUREMENT <br /> <br />T ~ ~ T <br />. -. <br />' <br />PERMIT .... .. .. ..~ ' <br />1. <br />.7 <br />..- <br />.Tr . <br />1 ._.~ <br />1 ~ <br />- ~_ <br />L' REQUIREMENT ...Y •_ _ - , <br />: <br />•i_ . i <br />~ . ... .. ,..J SAMPLE ~ I ' ::r; .r:J .. ~.i .:}•i..- <br />-t <br />~I MEASUREMENT <br />. <br /> <br /> <br />~ v ~ <br /> <br />PERMIT <br /> <br />-.. .."., <br /> <br />c . <br /> <br />.,:., .. . <br /> <br />': -,:: -.... <br /> <br />... .:. .:.:: <br />., <br />.... <br /> <br />.I. ~ <br /> <br />~r-'1.~. <br />, <br />' <br />( Y <br />:J - <br />! ll <br />. REQUIREMENT ~ _ - .i_ ,~. <br />: <br />L . <br />.. <br />. <br />) <br />a.J - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER i cc RnFV UNDER PENALTY OF LAw THAT i HAVF PER°ANALV Ex AMINED TELEPHONE D A T E <br /> AND AM FAMILI4R WITH THE INFORMATION sUBMITTED HEREIN AND BASED <br /> 01J MV INQUIRY OF THOSE iNDNIDUALS IMMEDi4TELY RESRJNSIBLE FOR <br /> OBTAIMNG THE INFORMATION. I BELIEVE THE SURntITTED INFORMATION IS <br />TRUE ACCUF4TE AND COMPLETE I AM AW4RE THAT THERE ARE <br />T VENALTIES FOR S <br />FORMATION INCLUDING <br />GNIF <br />BrnITT <br />NG F4 <br />E I <br />CA <br />]^/4~. <br />'1 ~y <br />7 <br />~~ <br />O ~ <br />/ <br />-i I <br />SI <br />N <br />U <br />I <br />LS <br />N <br />THE Posslaiurr OF FwE AND IMPRISONMENT SEE u3 U5C 4 r001 4ND <br />rr include Imes u <br />33 USC 4 1319 (Yrnalues undo Ihcss snmres m <br />In SIGNATURE OF PRINCIPAL EXECUTIVE 7. <br />{{// . <br />- TYPED OR PRINTED . <br />p <br />SIUOUl1 and nr nravmum rmpnwnmcm ni bnurcn 6 mpnrbs and 5 lear.l OFFICER OR AUTHORIZED AGENT GR <br />E <br />A NUMBER YEAR MO DAY <br /> O <br />D <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (He/errnee all allaehmen6 here) <br />EPA Form 3320-1 (Rev. 9-88) Previous editions may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 _ _ _ _ PAGE OF <br />.L .r ~'r_ ' ._. . _ <br />