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PERMITTEi IADDRESS(lnclude Fariliry NamdLocalicn i/Ogerenq <br />NAME :If crC rtt., t.r ~,.. <br />)~~gTf'I~ <br />ADDRESS F.. F .. i F' ~ f 4 ° ' ~i' ~ f FY <br />~ P.U. °7X Sn <br />^F't.G "~ x1625 <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM MPDESJ FOTm ApprOVed. <br />DISCHARGE MONITORING REPORT (DMR~ OMB ND. 2040-0004 <br />Approval expires 0531-9B <br />PERMIT NUMBER DISCHARGE NUMBER _ ~ T ,. T . „ <br />~,.. <br />MONITORING PERIOD r r " - • f it ••• •~ •~ T T t T ~ •• .' ° ,~ •' `• <br />YEAR MO DAY YEAR MO DAY <br />FROM 9 0 7 '~ 1 TO n ~ , ^ ~ n .. ...~ ~~ - ^.^ v n . r .. ,..., <br />!zo- ) ., (zz~zsl (zazs) (ze~z>'1 Ra-zel (3oa0 . ~~NOTE: Read Instructions befo ~pleting this form. <br /> (3 Card Ony) pUANTITY OR LOADIN (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER 48-53) 54-61 ? (3a-45) (48-53) 54-81 EX OF TYPE <br />(3zJ~) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS l~~1 (~LSa)s 69-70 ' <br />o j SAMPLE .., .. .. .. .. .~h+ / •~ <br /> MEASUREMENT <br />Ci)R7') 1 [1 7 PERMIT 4#rMQ. R aQarQ~O4F "` ~ y: ~ ,.~!~~#13Q 4~.(1 NCa'/ 3Af? <br />':F'F'f.t)cN': GPJSS Pa!,I' REQUIREMENT wr;~- ~ ~ ~w* nx r.t w pq <br />~'?L:65, ,t:T'L°.9 '; (,r SAMPLE , .. .;.~.;. ~ 't^:Xr.~a / ' <br />,~ <br /> MEASUREMENT <br />JJ't'+`~ I ll 11 PERMIT RritPOSC R.p#~pP RICgg, T ", ,.5 ~ NCP/ •$RF# <br />' F :' L II': F 1' C P 1 i" '! ~ t' I r REOUIREMENi y.~ Y'',y ~' .. r/ I w H <br />`7L ., C';t .'P.;`•' SAMPLE a.^i~~. _-..r .. fit{. ..~ r t ;) <br /> MEASUREMENT <br />('t"1 `'^ 1 J 7 PERMIT. 9#p#4R OrbOR4 Er RO'*?Kt#tOt" ~iy yy~r pp yp~ <br />~: F c 1,11 I•: R T ~'• ~ S ^ " ~ [ 'I ~ REQUIREMENT ~ <br />M ~ A' .. <br />FLnR, T`1 ~JgnU[T 0' SAMPLE ( ^~9) ... ..... ... .:. ~.,. <br />'Fi:U; "Pk FATM£q' PT.A" MEASUREMENT <br />7U;)SJ 1 p ~ PERMIT REPC#RT RLP7RT 16$slr~e#!t "~ItfftOt## a#4r01#O «•, . M>*£/ R4'j'~ <br />fF'i.!)F+'? I;pJiS VA1.U. REQUIREMENT jrJDR lIM6 RR[Lf CJt "^n ..H*r «;~,.. I <br /> SAMPLE <br /> MEASUREMENT <br /> PEAMIT _ ~ ~~ ~.~_: <br /> REQUJREMENT ' ~ - - - <br /> SAMPLE <br /> MEASUREMENT <br /> ' =~ .y <br /> REQU)REM):NT ~ es.l <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />r <br /> REQUIREMENT - .. - "' <br />NAME/TITLE PRINCIPAL EXECUTR/E OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO <br />ATION SUBMITTED HERE NALLY EXAMINED AND <br />IN <br />AND BASED ON MY TELEPHONE DATE <br /> <br />Ri <br />h <br />d M <br />II INQUIRY OF THOSE INDNIDUAL ; <br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />T <br />BM <br />TTED <br />NF <br />RMATI <br />N I <br />TRUE <br />/ <br />c <br />ar <br />I <br />S <br />F <br />TTV Ir'Oll rtlPrltal A4a fla( <br />Pr THE INFORMATION, I BELIEV <br />ACCURATE AND COMPLETE. <br />PENALTIES FOR SUBMITTIN HE SU <br />I <br />I <br />, <br />E <br />O <br />O <br />S <br />I AM AWARE THAT THERE ARE SIGNIFICANT <br />G FALSE INFORMATION <br />INCLUDING THE / <br />~ - i~ ~ <br />~ '' <br />970-870-2712 <br />I O ~~--TT <br />d~ /n1 <br />~ 1 <br />: <br />3 POSSIBILITY OF FlNE AND IMPRI <br />' , <br />SONMENT. SEE 18 U.S.C. 4 1001 AND 33 U.S.C. `SIGNATURE OF PRINCIPAL E%ECUTR/E <br /> <br />TYPED OR PRINTED ss under Noce smnrtes may Inc/utle lines up m f10,000 entl ar <br />4 t31 B. (PeretG <br />mvimum impnsonrrrenl ol5enceen6monMS erld Syeers.J OFFICER OR AUfRORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all attachments here) <br />G:.Y"fLEfldLF: S}L'n ~ ?.7"T' ¢}IYEit °7R ~in•p,?99k P3prTD °,Ey"~_cv~._T.9.T. n^ •••. ^~p pj',J(1rgPwtsN9'~, r'T1. <br />.;??ASP G.Yi? `DL'•' 4~'A_.Tc(5 ?~J7TPsJ Tr^ 9T.•TH(F' S?'~tl iS ^vgPp•;°-t, rtgn•nlr ;q.rDLTKG IMS4pT1f"t'Tr+uq_, T~ <br />EPA Form 33261 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />QOJ3N/490u12-152 t <br />