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PERMITTEE NAME/ADDRESS (lnrlude <br />Faeilil}' Name/loealion i! di!(errnll <br />NAME _ +-..~ -.- .T ~ -_ ~. ~ ~J-r•-•. ,--I: ~~ .~ _.-, .- - - - <br />.. <br />ADDRESS ~ . - • <br />_-- ly~~.l-J.~_a.4-t~------------- <br />FACILITY <br />LOCATION <br />- - - - - - - - - - - - - - - - - - - - - - - <br />- - r .. ~ .-. - . <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NFDE$) <br />DISCHARGE MONITORING REPORT r DINH) <br />(?-le) ! I ]-191 <br /> <br /> r , <br /> PERMIT NUMBER <br /> MONITORING PERIOD <br /> YEAR MO DAY YEAR MO DAY <br />FROM _ ~ TO ~_~ 1 J <br /> nn-rl, ,+~_III r?-rsl Wean r~xavl rn-In <br />_ Form~ApP!oved. <br />_ .T I~ i OM8 No. 2040-0004 <br />.Apprgval expires 10-31-94 <br />.:.:. (. :i ~ ~ 1 •.:. <br />NOTE: Read instructions before comlpleting this form. <br /> (? Card Oulpl QUANTITY OR LOADING !~ Card Onl)'l QUALITY OR CONCENTRATION <br /> <br />PARAMETER <br />1?6-?il (54-611 <br />(7R-?5/ (?6-S;) ($?-61J <br />NO. FFEOUENCT <br />Ov <br />SAMPLE <br /> EX ANA <br />r515 TYPE <br />!3?-371 L <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS +VI <br />6+ (64]el <br /> ~ <br />1 l6?-69) <br />3 .. ~ ' . <br />~ SAMPLE .... .Y 1 <br />r , .'t.: ~ :: ' :f:r: ;;:~=: I <br /> <br />MEASUREMENT ~ <br />~ / V I°i>`~ <br />V L , . a <br />. _ <br /> <br />dJ is I <br />PEP.MIT ... <br />:~. -.: '.- ._ <br />__ <br />-.:. /[:..: <br />..,..'..' <br />.`::- •.. <br />:.:.: <br />~ t _ <br />' <br /> <br />ri I ie REQUIREMENT <br />_ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEA Sl1REMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERnFr UNDER PENALTY OF LAw THAT I HAVE PEREONAUV ExAMwEp TELEPHONE D A T E ~ <br /> ANp AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ON MY INQUIRY OF THOSE INOI`/IpUALS IMMEDIATELY RESPONSIBLE FOR <br /> GBTAINING THE INFORMATION. I BELIE'JE THE SUBMITTED INFORMATIOIJ IS <br /> TFrIE ACCURATE ANp COMPLETE I AM AN'AFE THAT THEFE ARE <br />SGNIFIGANT PENAUIES FOR SUBMITTING FALSE INFORMATION IN' _UDING /~ <br />7Q Q/ ~ <br />1~~ 4S <br />I <br />Q ~ <br />I z <br /> THE PO551BIUir OF FINE AND 1MPRIBONMENT SEE IB use 4 Ic I ANp <br />~ i I <br />J <br />O SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />(/1p I <br />7 <br /> <br />TYPED OR PRINTED ~3 uEC 4 1319 (Nmelues undo Ihrse smrure+ mn <br />u <br />C <br />nrs up ro <br />d10000 anJ w maumum Impri+onmrnr or hnueen 6 monNS~unJ~S )'cars./ <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />TEAR <br />MO <br />DAY <br />COMMENT AND E%PLANATION OF ANT VIOLATIONS lNelercnce al! a1laBlmenl5 hire) <br />E A orm'3320-f iRev -88) Previous etlitiohs may be d. - r IREPCACES EPA FORM Y-40 WMCi-I MAY NOT'9E USEDI ~; ~ ; ~ ' - ~ r PAGE - E1F <br />- _ - J . <br />