|
PERMITTEE NAME/ADDRESS (1"drB FrWry Nor/fnranwl I10rfirn+U
<br />NAME ^Y'r> - I v,T r: p ^-~ "rT L, .,
<br />ADDRESS .
<br />~ ~ i ,. - ..., T , ~ . f ~~' a ` f,
<br /> r r
<br />..
<br />
<br />
<br />FACILITY
<br />i
<br />LOCATION
<br />
<br />NATIONAL POLLUTMT DISCNMGE ELIMINATION SYSTEM INPOESI Form Approved.
<br />DISCHARGE MONITORING REPORT lOMRI F t ,. ,• ~OMB.No-.2040-0004.
<br />!1.161 117-191 ' -
<br />^~(1.)Z.IT~'( nom-/ (. _- Approval axpiroe 05-31-98
<br />PERMIT NUMBER DISCNMGE NUMBER ^ _ - . .
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM U.' TO .I .. ,.: ... .. .., , (__ I
<br />l1azN lzaz3l rzaz5l /z6-zn n9-z91 caa-311 NOTE: Raed Inslruetipr before eomplstlnD this form.
<br />PARAMETER !3 Grd Onlyl QUANTITY OR LOADING !~ Grd OnlYl QUANTITY OR CONCENTRATION ND FREpUENCY SAMPLE
<br />l3 (06.53 (5x611 l38-451 (46-53 154611 OF
<br />Z-371 EX
<br />MA
<br />YSIs TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 151-sJl L
<br />(64661 /69-701
<br />~''~~'
<br />' SAMPLE :. ~Sfr#
<br />` . • • .
<br />.. .. _
<br />( t /~ - '
<br />~
<br />f '
<br />I '. ~ L R ;. ~.?'-' r' a s , (,
<br />~ MEASUREMENT r ~ ? • ~ ~ C> /f~ 1..1lIlIJ
<br />1.,.~ L
<br />ll :! ~ PERMIT Ads;k ~~~Y ..; td.': r :k#k 4;r:nt:» T,n ~. .. ., ..,r
<br />~ ~ • . ?''v'-~ 'O,AR
<br />` . U E: '''" ; . R J S S Y A. L U P, REQUIREMENT -
<br />'I'-Y EH, NJT';:KPIALLT
<br />J L,.~JLV.;D SAMPLE
<br />MEASUREMENT ':a;<^-;c ;:~aa.'k .::kt:•.._.•
<br />(O,D3
<br /><~.G3
<br />( I It
<br />~
<br />~~~ (
<br />L7 ~~jll)
<br />~:-1 )'.lu I D rJ PERMIT .t"~'s.?.OSt `v ~'CarkOr ' t: Ckh d=,`•~tYcC: t,: ~-t 3n,T Ij tr Cf?4i ( ~Y^c
<br />"~
<br />;R98
<br />'.'~UENT ;P.OSS YAi.:'r REQUIREMENT trxk ,~.
<br />~'. 41'r' nsT'IY Mu ur/f, r"`Dv9f1
<br />-J:..cRs i'7T°.YTIA I, S.~ SAMPLE ;rt"•gr:{: ::k ",.^--^.:
<br />~.`~~."~ tOt 1
<br />i:i .~LY~D
<br />' MEASUREMENT _
<br />I~ lI •~ C, ~~ ~ ~) (~fJ ~~;J
<br />1JUU l 0 ~
<br />' PERMIT ~0.p~. .,^.'kC'X S= .,. w:'t `- :t ....>..,:.. r,~n~T ~t~ 'ry..../ _
<br />-F';,U ENT ufl'.;iSS "~! "` REQUIREMENT ~n'ty a'• "" "'Y -,T r
<br />~.~'. .; r:HF.S P.4 !?'T' SAMPLE :k,. ,k .,; .. ,. r. yr.~,rk
<br />.. ~ /"
<br />' ',
<br />~/
<br />"=?'J ~:RA 9LE MEASUREMENT (Jr ~•~ I"-I .~V ~ ~ )!1
<br />•r r (i1~~rJ
<br />1.1?.23 I 0 PERMIT,';` `x~.^a ..::{:^, .x _
<br />~' T ~ rY a_
<br />°L'J:':9T u'ROJ' '1 ,n L')°. REQUIREMENT ~
<br />... -
<br />4rt .,3 .rr
<br />r
<br />-/i
<br />',:i-' IH ~O'i ~~~ j lR
<br />F SAMPLE IC (
<br />~
<br />O
<br />I ^~ ~/~
<br />I ~ - 1
<br />rJ - .. -
<br />i' r
<br />{~
<br />C
<br />'
<br />A'
<br />iRf.AT""q"''^ oLAYT
<br />!''tJ MEASUREMENT ,,
<br />.
<br />SO 1 LJIJ
<br />O'dt :
<br />t r ~
<br />•1
<br />~ I/J!~/'
<br />11';lJ I 0 "' .PERMIT R!•'~7°T REF~~RT ~y::. ,...
<br />
<br />._.. , •;
<br />..... ..
<br />a
<br />.` . ..
<br />•
<br />!
<br />' t, •~ ~• ' ..
<br />'y' F v it F.'f : ~ [ { " i t, O c .REQUIREMENT 300A AYE 'SAILY 'fY ?l i;~ ,
<br />I L 4 N 0 ~ :'. ! SAMPLE
<br />
<br />.....
<br />r rt "" °'` ) q
<br />~ I
<br />
<br />~,wA.-
<br />• .
<br />
<br />., ..
<br />~
<br />
<br />~,.:. ,. .. -y~
<br />~
<br />n,\ ~•
<br />T.i ~: A L MEASUREMENT O I/I
<br />/
<br />I 1. .
<br />Lh I~~`fUl~'l
<br />' X066 1
<br />.
<br />"
<br />, PERMIT #43 3'k :t I r ~ -= 1 ":?' .. .....,; .,. .,e_ ~ ;_>. -
<br />-r
<br />'./
<br />r Y
<br />;, ;J t." .: I
<br />'i~ ',C~'
<br />.. REQUIREMENT f
<br />143:^ ~AR ~"_~ ~
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW TNAT I NAVE PERSONALLY E%AMINED MD
<br />AM FAMILIM WITH THE INFORMATION SUBMITTED HEREI
<br />MD BA
<br />D ` TELEPHONE DATE
<br />
<br />I ~ N:
<br />SE
<br />ON
<br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIB
<br />E FOR
<br />t
<br />"
<br />- L
<br />OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE
<br />ACCURATE MD C
<br />I
<br />MRETE
<br />M ~ J
<br />~
<br />~,~~
<br />~ -
<br />= ll V I Y0 1 ; (,'- t
<br />' I :• r. ^'
<br />P P ,
<br />O
<br />.
<br />A
<br />AWME THAT THERE ME ~
<br />SIGNIFICANT PENALTIES FOP SUBMITTING FALSE INFORMATION
<br />INCLUDING ~76~ s~
<br />.
<br />~
<br />' - ~ -
<br /> ,
<br />THE POSSIBILITY OF FINE µD IMPRISONMENT. BEE 1B U.S.C. 1 1001 µD GB NATUR
<br />
<br />
<br />TYPED OR PRINTED
<br />U.S.C. E 1 J 1 e. fPerlsi. ul0~r dwr mIRGr. m.y A%NAN lvw. W ro J IO,OW
<br />wwmuAnun irlPn'sw.we a/Wfrwn smenNa rNSyw.l 610
<br />E OF PIIINCIPAL EXECLRIVE
<br />OFFlCER OR AUTHORIZED AGENT
<br />
<br />NUMBER
<br />
<br />YEAR
<br />
<br />MO
<br />^, CODE DAY
<br />.........._... ~ ...._ ~... _~...•..~.. _. ...., ....~ .......... ...o..., .,.~. e.. ...o......e...., .....i
<br />~ .
<br />EPA Fam 3320.1 108.951 Previous editions may be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USEO.) ~ , , ~ / ~ „ ~ ,i ., T :, PAGE -, OF
<br />
|