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PERMITTEE NAME/ADDRESS Owersr FrY~ryNa/L«mrm dD111Nwq <br />NAME' ' . ' ~ - .. - <br />ADDRESS ~'• I :) ; ~ 1. r '~ ~ ~ ~~ O I' ~ r - v ~. <br />FACUrfv <br />LOCATION <br />t j" v,p:lHT'~ ~o..r .yF c ;'. [. 4:9Y <br />NATIONAL POLLUTANT DISCHMOE ELIMINATION SYSTEM (NPD£$) Form Approved. <br />DISCHARGE MONITORING REPORT IDMRI - - ~- - , -. +OMB~No:•2040-0004 <br />T-I51 I77-I91 ~ ' - R <br />-- ~ ^ ~ ? 7l ~ 11 ^ T '1 1 ~ ~ • ~ APProvel exPlf? X06-3 -98 , <br />~~~ . <br />PERMIT NUMBER DISCHNiGE NUMBER -+ - T r i . <br />MONITORING PERIOD Tr ^ ~' <br />YEAR MO DAV YEAR MO DAV __ <br />FROM /1 1 TO +'/ r 1 •~ - .~ i •. T .-r• a q ~ ~• I .4 ': ;" <br />!?0-111 !TT-131 lT4T5l l26-T71 !T8-T9l !36311 ~~NOTE: Raed Inetructione before completlnp thu form. <br />PARAMETER !3 Grd Onlyl QUANTITY OR LOADING !~ Grd On/yl QUANTITY OR CONCENTRATION NG FREDUENCY SAMPLE <br /> letr53 150-efl 138-a51 1e653 !545!1 EX °F TYPE <br />l3T-371 ANALrss <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !sT-s]I l~.581 169-701 <br />;AV'.~-', ~-.. 1- <br />^^ SAMPLE r, r: RC?~ :. Cr, ...., ntk:-•: ( ,Q) <br />' r'C7Y G!t .i r.: MEASUREMENT 0,585 'r~rJ' ~ ~ /~I ~I'C-T~ <br />11'113 7. l} :I ~ PERMIT ~k'T arx ~kG y: r.#p,~,~ O r;:~ t±~tx':r.. 'I.(1 n^p{Ivm . 4C: <br />/ "7 <br />'.>+L^ <br />::F?LUF'•: "'~.i°. 'J9LU REQUIREMENT :': #k r; 30E3 4Y^ ART T ~'iY •C;/f . <br />MfJCPH . <br />''i..~r I` :;~'iil?~~" :ail SAMPLE ( X31 ':-'F7:-': t: ,.fi r..1; •. ,; r:±:+:±:i 1 <br />iN~:?l! T'+4'AI""'. "L 11r MEASUREMENT uI~ <br />Ir2~'"l pp <br />Z•~~'O ~ /3iI [~LLTD <br />'.CU~O 1 U J PERMIT RE;POR! REPORT 3##1k;L# r:y":vlt-y .##>ri:;: - #': r; S NC£./' 'ALCM") <br />L'r'}'LUE'.i'" G"~15 Y4LUs REQUIREMENT 3004 AY~o DAILY ~hX "!GD - ~ #'k :!# Ak <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 />NAMEITITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AMD TELEPHONE DATE <br /> AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON <br /> <br />k-chard MIAs MY IMOUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS /' <br /> <br />i <br />l P <br />l TRUE, ACCUMTE AND COMPLETE. I AM AWME THAT THERE ARE <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING <br />9 <br />Q B]D-2712 <br />8 <br />Z~ <br />0 <br />ronmenta <br />anaaer <br />Env <br />e , / 9 <br /> THE POSSIBILITY OF RNE AND IMPRISONMENT. SEE to U.S.C. E 1001 AND ]] gIONATURE OF PRINCIPAL EXECUTNE <br /> U.S.C. f 1]te. IPwrleir uvrr FrNar mnnrr mry McNW fires. /p ro SIO,OOD AREA <br />TYPED OR PRINTED r.snmrrYnun inpnAwnwrtW alrrnemmma rNSYAe'a/ OFFICER OR ALITHORI2ED AOENf CODE NUMBER YEAR MO DAV <br />CVMMLIY10 P11NU CAl'LXnnIIVN V~MIY1 VIVLAIIVIYD IRBrereDCl el/eReCOnIeDrJ Dere/ <br />Yi=:';~"INc 1"-n'v nY°u•.-:h' :~\Cr'w~.~.hr-.~ IIST~~.~ A -ICga;, ,p,ruuPTfr ..I,E, ^.r "•v'v D.Vr - . <br />`- L 'L1. f. "' .• I°: T`: cad+! <br />-: i'~L ;S ~JLI -..r^ir E, ," $lI•I r:- :1~1]ar 7151 4': '1 q')7A T~f]D~I-i TI{p -~C--'••T T1r~ ..~T-'!-T. .:F ~r" ~-•. <br />EPA Form 3320-1 108.961 Previous editlons mey be used. (REPLACES EPA FORM TAO WHICH MAY NOT BE USED.) ~ n .1 ~ . / ~ r (` II n ~ _ 1 7 1 ~. PAGE 1 OF <br /> <br />