Laserfiche WebLink
PERMITTEE NAME/ADDRESS (Inrlude <br />Fariliq' Name/Loralion i! tli/Verrnrl <br />r <br />NAME--.~~~._~_._ .,~ <br />a. L ~_y_~_ v1i_ _ <br />FACILITY <br />- _ - _ _ _ _ <br />LOCATION ____ __ _________ <br />1. C i'.J I'T', <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDE$1 <br />DISCHARGE MONITORING REPORT (DM11R1 <br /> <br /> <br /> -e-,.z~ ; <br /> PERMIT NUMBER Rc¢ ., <br /> MONITORING PERIOD <br /> YEAR MO DAY YEAR MO DAY <br />FROM J _'-!. .. I TO r L' . <br /> I?n-+n rn-rl ra>sl nA-?~I r?.a-~91 Im.rll <br />.'i 4 ~ :~ Form Approved. <br />_ -+ ~ OMB No. 2040-0004 <br />) - - - ~ Approval ey~pires 10.31-94 - <br />,NOTE: Read instructions before ompleting this form. <br /> (J Card Only QUANTITY OR LOADING (4 Card OnlFJ QUALITY OR CONCENTRATION <br /> <br />PARAMETER <br />(.IA-S]1 lJa-Al) <br />71 (iJ-All <br />178-ai/ (aA-5 <br />NO. FREQUENCY <br />of <br />SAMPLE <br /> . EX ANALT515 TYPE <br />I i?-J71 <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS d; d9 <br />70 <br /> r5l <br />l IdJ-dFl - <br />) <br />t <br />~ SAMPLE .:'I':I ::4 .-. .. :i :: ~.::,: '.: ' j-?~ <br />I <br /> MEASUREMENT <br />J., UI '~ PEP.MIT :x (. 1-(.:: e: -. -.. ~ ... r ~ <br /> -REQUIREMENT <br />• <br />IJ vA i=• -_ .:L.1 dL~ SAMPLE ... 1'.... :., ~?~ <br /> MEASUREMENT 1 <br />r~ <br />~'- i~. I 1 ~ .. <br />PERMIT <br />... ~,.; .. <br />...: '.. <br />~ <br />_• T.~ <br />- ).•,. <br />~i. <br />Ir ~ <br />- <br />' '. ~1 .. ~ ~7:, fa I •.-,II ., <br />- ~.. . REQUIREMENT =~f 4-tf <br />- <br />- •• ) T './ ' <br />J - ) .:. .J ~ SAMPLE i'. :. .:'.: ~: ... ':} ~: .. .. f,: . :;:y ~ .,1 <br />~ <br /> MEASUREMENT <br /> <br />i <br />.~ ~ ~ J ~ ) PERMIT ... <br />.u .. , r, - <br />~ 'f v!. <br />.... ... <br />.. . ~ ~. . <br />~ I _ 1.,; j .) <br />• REQUIREMENT .':f- ~';: 1 / I <br /> <br />. ~ ~ <br />.r ,, <br />_ LJ !~(! - - SAMPLE ( ~, <br />... <br />~: ;t .' <br />.. <br />sis ;::; <br />:~.r .. <br />~ .. <br />- ~ ).. ~ <br />~ L MEASUREMENT <br />J,o Sn ~ PERMIT _- <br />- ~ ... <br />- -~- ~ .... ._. <br />~~ ~ - .. ..-. .~; <br />~ - .- -! <br />l <br /> REQUIREMENT ::i_,. <br />r : <br />~-. T':3, ~:. .~ i .I. SAMPLE ~~ :. : .:. I <br />s ,/ <br />iI }rJL~a-.~ MEASUREMENT <br />/ ~:: ._ a PERMIT ~.I :a:.' is :: ~ - ~. r. ~.. , <br />I .. 1•• <br />• <br />` REQUIREMENT I ,+ s _ <br />~1. l •-. . <br />.J.. <br />. SAMPLE .. ... ',~ .... i-:...-•- <br />_ MEASUREMENT <br /> <br />~_I Imo... 1 .- PERMIT rl ., - .:i .n- fi:. .., ~!"- ~ ~ i <br />~: T 1) - <br />. <br />, L'I ~ ' REQUIREMENT _ <br />I .. <br />. <br />J- I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALrv OF LAw THpT I HpvE PERSONALLY ExAMwED <br />' TELEPHONE D A T E <br /> AND AM FAMILIAR N <br />ITH THE INFORMATION SUBMITTED HEREIN. qND BASED <br /> ON MY INQUIRY OF THOSE WDNIDUAL$ IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION I$ <br /> TRUE. gCCURATE AND CQMPLETE I AM AWARE THAT THERE ARE <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORA1pTION INCLUDING <br />f~~ <br />9~u ^_ <br />lX! <br />Aq'1 <br /> <br />THE FossBILITV OF FINE AND IMPRISONMENT SEE IB USC 4 fool prvD <br />IGN <br />T ~~-~ <br />V ~((~ <br />'1 <br />l/ / ~~ <br /> 33 UsC 4 1319 (F <br />ramres ma <br />nahies <br />d <br />Ih <br />' 'ncl <br />de G <br />m A <br />S <br />URE OF PRINCIPAL E%ECUTIVE <br /> <br />~- TYPED OR PRINTED r <br />un <br />er <br />csc s <br />l <br />u <br />nas uy <br />fIlI <br />P00 and or maarmum imprisnnmrnr al berumn 6 momhs anJ S years.( <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> , CODE <br />COMMENT AND E%PLANATION OF ANY VIOLATIONS (Relcrenre all a!ldchmenls here) <br /> <br />.. _ ~ T._ - - -' %--.I-. , -- `I !? ..T _- - . .. '-)~:. 1. <br />EpA Form 3320-1 (Rev. 9-88) Previous eddions may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 PAGE OF <br /> _ _ _ <br />