|
PERMITTEE NAME/ADDRESS (1M,L FsWryNswJlawlen dOls...ne
<br />NAME ^ v ~. ,. .r . ... .. .. - ,.
<br />ADDRESS ~~{ ~. ~ ... ^ .. _ -~r l T. w ;
<br />~r.~,~. I ,. .. .. .. . I
<br />FACILITY
<br />LOCATION
<br />•~~ :T ~ 'r.; ,. s. 1. 4I'"q
<br />NATIONAL POLLUTANT OISCHMOE ELIMINATON SYSTEM (NPDE$) Form Approved.
<br />DISCHARGE MONITORING REPORT IDMRI .,-v M , „ -, ,, ,.., OMB-Noo2040-0004.
<br />1Z-161 17-191 '
<br />~ "• ~ ~) ; 7 j5 q ^ ^ Z 1 / - ,r ^ - ~ \ Approve expires OS-31-98
<br />4 ..
<br />-PERMIT NUMBER DISCHMGE NUMBER _ •• ., 1
<br />MONITORING PERIOD ~ T
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 11 ::' IE TO v 1.. ,.; .i: :~ ., ~. ~.r ~~~:a^"'= ~__~ ....:
<br />(16111 171-131 111-151 126-771 118-19/ !36311 NOTE:, Read inelructlone before completing this form.
<br />PARAMETER !3 Grd Only QUANTITY OR LOADING !I Grd On/yl QUANTITY OR CONCENTRATION NO FREQUENCY gAMPLE
<br /> !46531 150-671 13BL51 106-531 !5461/ of
<br />131-371 EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 161.691 !64661 169.701
<br />'.. ~;I'1.:: `. r. I" SAMPLE
<br />MEASUREMENT :.:`mot ,r: q;,: ....
<br />~,~ ~ _
<br />f1 I ~ r , ~ \
<br />L~ L,, /..
<br />i'
<br />~ q
<br />i~(~
<br />~/
<br /> ,
<br />: ,
<br />:;. '~: i ' PERMIT ;: t,:,::~~y".r .-: ~::x :A ~~ r : ,. ~,-x~;.t~ 5!!R`.
<br />
<br />.
<br />-,.~:-n....T vPr7/ Hk; •_/
<br />
<br />~
<br />i'
<br />-
<br />L1(`, ':' rr n e : r)c REQUIREMENT r=;*R ~ lnp a S'J^, '1R? TY F1 X r"' .M!11
<br />t a
<br />r SAMPLE
<br />MEASUREMENT .. Y 7 r~ ^ . ,-.- ^ .. /1
<br />l~ r4 ~`-- ~ ( t ~+, O ~~ / ~/lf/
<br /> / 71 /
<br />~'I'.UP '_ (, PERMIT 3YRR33 :::~=FO.f'k '~ ;:=:: ~j.ti ;s r:r~^cY,t# ~.F) ` F°RLY iF,A.~
<br />• Fi LU~~N^ ,Fl i°, ~ ~p„ 'REQUIREMENT ~ 'tT NTrtY+! 1S4XT«t}h. qq
<br />;J~.LD~F rar+.i.
<br />-
<br />' SAMPLE
<br />MEASUREMENT •~~~•.•~" ~... „=:r:':=:
<br />~ y
<br />~ ~
<br />f r~)
<br />~ `
<br />) I'~
<br />:: ~
<br />~ n
<br />~ h, 7 ~. 7 / p`
<br />.. 3C O 0 ) PERMIT °. 'rp ;{' ;:¢:-r,: ;r q: . 4~, 4•.-,;=....
<br />.-.- VF•~.~~,, ?^-;~^~~ ,. ~r
<br />'
<br />~
<br />~
<br />
<br />_ ~QF!'~ceTS RF:L'.1
<br />REQUIRENIEN*T
<br />...,.,.: C~Y~10 3~^~ av^. ^BTjv .y .,~/. x;l r+. '
<br />~
<br />•
<br />i-~:+`i6 TQT R.L SAMPLE „ ... ?;r :p'.: ,-yr.. ~: ~
<br />~ lCr / )) f
<br />J/
<br />i'.'~? ~HD~;D MEASUREMENT ~ \~ ~ a PJ Cr
<br />
<br />_r1 j 7 D.
<br />JL
<br />PERMIT
<br />:>{::; ;`t C:¢
<br />..'s.^. •:.^rt•+ :'
<br />+::',:~
<br />`#~'t#d-^,•
<br />~r
<br />7/1
<br />::L:/
<br />~
<br />;n7 r,
<br />.
<br />-. '..U~NT 6R.Q55 1'S `q11 REOUIREMEN7~ '.r_~.. T^^A. Ar... n4i tY 'y "^'L "•,-"'a
<br />a :l.?e:i SI•TTL"r~ T.~ SAMPLE ~"C4f ~. 4'.S#~': ':
<br />( 1~
<br /> MEASUREMENT ~ ~~ i;~~ i ~! ~ ~ t\
<br />.'! 5 `i ,. " 'PERMIT `#~.X }c ~ ^. r. ;>.:x s<.` ,-: ~ w+h": ~r o D~ n^ rt c ,
<br />. =:~~,"1"3 C'. RF•L3Y .REQUIREMENT ..`4 i0-' A't^ n3 rrv -!F ",/I. 'd0t'.' i .
<br />ILLD$A 5-,_~r. ~'AI'LF' SAMPLE
<br />MEASUREMENT .FC;: r. .: ey :Aiit#'t .L.Y:...,:...
<br />< D/ I
<br />O• ` ~ .. c)
<br />O
<br />3/~~Ci ~~
<br />, -~ II
<br />'.LLS 1 `~ PERMIT .~•-.~?:: >~ 4+'Y :t--+?; ':t ;: ;c ~; ;ertO t)F`(.n ~'!' p^)•n,q~r
<br />
<br />~
<br />y•,.-F~/ ^
<br />L!1ctiT ;;F ~~ . - ~,. - REQUIREMENT f. ...: ~^f ~ tY~. .,A+Tv wg ./ rr
<br />.. ~-, ,: ~~ .
<br />~- 4~~JD :`~.o.-- SAMPLE ...,,
<br />`+ RZY-'. 't •:
<br />~ aa,. .; ..:.
<br />,.. r ..
<br />..
<br />` (
<br />1 1)
<br />. ti F. (!' y _ ..:: ,. y '? :. .,' a MEASUREMENT ~ /U .I I~i ( r
<br />I .. _ .. L ~ ., PERMIT ., t ~ .- .. , ,- , it c. ' .. .. . ^'k' . T t
<br />- •' L ll 9. N'" ; ~ 1 '. ; t - n ' REQUIREMENT . , { .. ~ m r. ~~ + ^ / !
<br />+:
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENMTY OF LAW THAT I NAVE PERSONALLY EXAMINED MID TELEPHONE
<br />
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED NEREIN; MID BASED ON DATE
<br />
<br />11
<br />~
<br />I MY INQUIRY OF THOSE INDINDUMS IMMEDIATELY RESPONSIBLE FOR
<br />EVF
<br />NI
<br />w
<br />A
<br />S
<br />E
<br />I
<br />O
<br />O /
<br />~~
<br />/
<br />~
<br />~
<br />-
<br />,~
<br />'(lr Yl
<br />~. TRUE
<br />A000RATE
<br />D
<br />COMPLETE
<br />AM
<br />AWARE
<br />TN
<br />AT
<br />THE E
<br />ME /
<br />J
<br />~G ~/n ~ I
<br />7" OL
<br />-
<br />I .
<br />.
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FMSE INFORMATION
<br />INCLUDING ~ I
<br />~~
<br />/
<br />~ ,i PI +. t.
<br />- __ not
<br />' ,
<br />THE
<br />ITY
<br />D I
<br />B
<br />_ POSSI
<br />IL
<br />OF RNE AN
<br />MPRISONMENT. SEE 1B U.S.C. f 1001 MID 37
<br />U
<br />S
<br />f t 31 e
<br />/A
<br />Wr
<br />C
<br />Wei
<br />Y
<br />m
<br />A
<br />/
<br />d
<br />t g10NATURE OF PRINCIPAL EXECUTNE
<br />
<br />TYPED OR PRINTED .
<br />.
<br />.
<br />.
<br />r
<br />. In
<br />e
<br />rs
<br />nm. m.r
<br />rc
<br />u
<br />. ~w. w ro
<br />10,6Q0
<br />e+O tr nlA.MUn Yrtpis+wwlr W6rrrwn 6mgmla rM6yrral
<br />OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />GOMMCR I D ANU CAYLFln1A\ 1 Iurr VT nn + v win I was InerersnGe•en euecnmsnts nqq
<br />/~. 1• : ~ '. r - T ~ ~ - ~ ~ .. " : I . r ! = 1 . ) 7 1, ~. n , { T. \ ~ I ~ r) . '1 - T V , • ~ . ~ T -. / _ _ V l l _ , 1 . / 1 T
<br />/ ` F
<br />~~:, '. .J. _ '.~ ~' ,. 'r ~'.")i' _\~n )^ n'~'I ',c •1• ,,~Ir~ .. n._~ /,Tr _ __ ,y ~~ ~..- c./ p,
<br />EPA Farm 3320.1 108-951 Prevloue edltlona mey be used. IREPLACE6 EPA FORM Td0 WHICH MAY NOT BE USED.1 ^ /, „ -. , / ,_ ~ ,. „ ~ _ , ~ ~ ~. PAGE • OF
<br />/,
<br />
|