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PERMITTEE NAME/ADDRESS pnclude Fadliry NamNLocq(ion JDi$ermq <br />NAME <br />ADDRESS.. u + i '. <br />FACILfTY P d ~~ ~ ~ ~ ~ I <br />LOCATIONr17ti I <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MFOESJ FORn AppfOVed. <br />DISCHARGE MONITORING REPORT (DMR~ OMB No. 2040-0004 ' <br />Approval expires OS31-9B <br />~'nr -r ~ :, ,-, <br />PERMIT NUMBER DISCHARGE NUMBER (' r ) <br />_ ;! ^G <br />- MONITORING PERIOD - "" !' I' •'!~~ 2 ~ <br />YEAR MO DAY YEAR MO DAY _ <br />I FROM ')', -. ~ -, TO .T.. .~ ~ - -. .I _ ~ c ..i ,~ ;: ~ ~~ <br />(2621) (22-23J (2425) (z6-z>') (P6~Y9J 13as1J ~ NOTE: Read Instructions before T:ompleting lhisform. <br /> (3 Card Ony) QUANTITY OR LOADING (4 card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER 48-53) (54-61 38-45 (4653) (54-61) EX OF TYPE <br />(323 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~~ <br />IS 70 <br />69 <br /> (5ztol 6s - <br />..-_,I ,,T~Iq~. ~, ::'r SAMPLE •: ~.....~~ .,.~._,, .k [~ •, ;: X~.. ..,. .. :. .:..._ <br />. <br />( -~ ~ <br />) <br />_. , ~ ,; ,,, p. ~~ N • [ n MEASUREMENT <br />A " 1 R " -! :- PERMIT a# `-kQ# #####O : ea. - <br />180:40~i <br />#~a#±~+~ <br />#ea#~a <br />e~•- <br />?8L2 <br />~Ak1~ <br />:'(Lli ~" •'i' '. •.- ) REQUIREMENT g " <br />-ii/; -r.r /... ~ ._f <br />y <br />~ SAMPLE :?3-`.`•.'k - .. ~ ~~) <br />, <br />v <br />y ~ r ;~ ;, ; ~. MEASUREMENT <br />,'.C 1 ;! ; "".'PERMIT ^.#:>X## ###### v,. 1~O.UOp'1 ~ ," ###IR## -"##v0i##C -= <br />~ ~L3 $A~'.j <br />t P:.u i'3T .. i, ~S? v4LG. 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 />/ <br />~ <br /> MEASUREMENT ! (J <br />,~ ~ ~ [ p r <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ - ~- ~- '~'; '.~ <br /> pEOUIREMENT ~;,:, <br />NAME/TITLE PRINCIPA EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMIUAA WNH THE INFORM LAW THAT I HAVE PERSO <br />ATON SUBMITTED HERE NALLY EXAMINED AND <br />IN; AND BASED ON MY TELEPHONE DATE <br />/ ~~ /(;( t,(( <br />~ /~ ~ ~ /~ A, <br />' INQUIRY OF THOSE INDIVIDUAL S IMMEDIATELY RESPONSIBLE FOR OBTAINING / <br />/ <br />/, / THE INFORMATION, I BELIEV E THE SUBMITTED INFORMATION IS TRUE, r <br />( <br />~ <br /> <br />r <br />ACCURATE AND COMPLETE. <br />P <br />IIBMITPN <br />1 AM AWARE THAT THERE ARE SIGNIFICANT <br />G F <br />F <br />RMATION <br />INCLUDI ~ <br />/ <br />/J <br />/ _ J - <br />~ <br />~ ENALTIES FOR S <br />P <br />AND IMPR ALSE IN <br />, <br />O <br />NG THE <br />ISO <br />AND <br />./T /GN f <br />l~ / <br />~l ~ OSSIBILRY OF FINE NMEM. SEE 1B U.S.C. 4 1001 <br />33 U.S.C. <br />i SIGNATURE OF PRINCIPAL EXECUTNE <br />TYPED OR PRINTED rres upbif0.000 erM Or <br />mr~'mum lmpnsmmenr of Kneen Brrr~anfl~is entl Sutl~9 OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell effachments here) <br />.~. Phl;"' i.l,.'t .'i' i"Fy'!' ,. it;.i' ~F!7C ~: ;)rl °. ~.. os Pr!:'.T L:7n~ C!i.'~'"T'~. (, ~~. vl f' v") "I"' L` [,. ,pf. c,7', <br />°. .. ._ i Y": .t ..; I'- (LC`_<I) :1 ,` 1?TAr'" ryr~1T .. T')Y.I: ITY Tc~~• '; ~`JF"' c7oo ~.n~ <br />EPq Form 332x7 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />