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_~ <br />., <br />PERMITTEE NAME/ADDRESS rlnclude <br />Farilir}' Fame/Lorarion if diflen•nrl <br />NAME <br />.. <br />ADDRESS .T ~-v.-.-.--..~---_- <br />---~.1~.--...=ak-~-__-__-______ - <br />___-~.--_,-- __---_----~.~_.T~r __ <br />FACILITY <br />LOCATION <br />___J---~ --,------------- <br />NATIONAL POLLUTANT OISCN4gGE ELIMINATION SYSTEM (IYYDL$/ <br />DISCHARGE MONITORING REPORT (OS7R1 <br />(?-16) (17-191 <br />PERMIT NUMBER Disc+Awcr wuaeew <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~. '.-. +L TO JJ <br />nn-nI rn->xl v-r.I ~-nl .re_ial _ <br />_ ~ <br />J •_ ~ - ` r Form Approved. <br />_ OMB No. 2040-0004 <br />: -1 ~ ,1 .~ r ~ gpprOVal expires-t03_7-9~ .. _ <br />-NOTE RAad instructions hgfnrA emnnletinn this form <br /> (J Cdrd Only? QVANTITY OR LOADING ~ (4 Card Only1 QUALITY OR CONCENTRATION <br />PARAMETER <br />(46 - <br />i1/ I54-61) <br />(iF--15 <br />46-571 <br />Sd <br />61 NO FREQUENCY SAMPLE <br /> . ) <br />( <br />- <br />1 ( . of <br />(t?-77) EX ANALY95 TTPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> IG'EJI <br />16Jd51 <br />f6V-IUl <br />I <br />-. .- .J... <br />SAMPLE <br />... .. ... <br /> <br />~ ~ <br />.:._ <br />.. <br /> <br />' <br />l::5 ~I.L MEASUREMENT /// <br />T /~~p <br />VI <br />VrT, <br />,: L` ~ !(~ 1 . l MIT <br />PEP - _~ - .-•:}:: is ~~......w~ .. - <br />' <br /> <br />'i •I Sc - 7 . <br />REQUIREMENT <br />r - <br />II- - -- T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> RED UIREMENT <br />ryAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I cERnFY UNDER PENALTY JF LAw rHAT I HgvE PEREONALLV EzAMweD TELEPHONE D A T E <br /> PND AM F4MiLIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESwONBBLE FOR <br /> OBTAINING THE INFORMATON I BELIEVE THE SUBMITTED fIFOR'M14T IX. I$ <br /> TRUE ACCUPATE AND CCMIPLETE i qM AW4RE THAT THEFE ARE <br />9GNIFiCANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING <br />II <br />/ <br />~ <br />S <br /> <br />I <br />' . <br />rHE RosBleiurv OF FINE grvD IMPRISONMENT GI°E IB usG 4 lopl AND <br />33 USE 4 1319 (DenaII <br />CS un3fr Ih <br />s[ }1911/![ <br />mJ:' <br />I <br />IJ[ /i <br />~ ! <br />I SIGNATURE OF PRINCIPAL EXECUTIVE ./, II~~ff <br />~ <br />!•4/ //]],~11 <br />t~{1M'~J O~ <br />_ <br />TTPED OR PRINTED I <br />[ <br />In[ <br />I <br />n[a Y~ <br />( <br />7 <br />IIO.UW end or nu~imum impnsnmem n/ Annffn M1 mmlh. JW i uears.l OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br />COMMENT AND EXPLANATION OF ANT VIOLATIONS (X[Itrtnrt alI dllJi llmtn(5 lltrt) <br />•a . <br />LWA Fdrrlt'3320-t (Rev.' -88( /'r vious edi io7r may 6e used. ' ' ~ r I (REPLACES EPA"FORM T-40 WHICH MA OT B~ USED.) ' ' ' - `' - ' ° ~ PAGE OF <br />I. /.. .f.- -/ <br />