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PERMITT ME/ADDRESS(Incrude Faciliq•Namellecation ifDi$eenr) <br />NAME ~, A^,)i oTnT nr'. CnVOUr aT?OH <br />ADDRESS A ~~ [, : ~ j q r ^ n ~ o) rt <br />C~AT.~~ .^.~ N1f;~5 <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) <br />DISCHARGE MONITORING REPORT (OMRf <br />(Z-161 (1l- B) <br />^ PERM T NUMI3ER DISCHARGE NUMBER <br />NIONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ TO ° ° ~ <br />(3611) ~(2Y-3J) R4s51 (262]1 (TB-f81 (30311 <br />Forth Approved. <br />n OMB No. 2040-0004 <br />~` ~ Approval expires 05-31-96 <br />c _ crp~f, r7!•A. <br />c" ~ x•_'11 •. m~ [1,7 r),~ '•v <br />NOTE: Read Instructions before c plating this form. <br /> (3 Card Ony) QUANTITY OR LOADING (a Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER /48-53) (54Br 3B<5) (46-53) (5467 EX OF TYPE <br />(32x7) AVERAGE MAXIMUM UNfI'S MINIMUM AVERAGE MAXIMUM UNITS (szm) (~safi8)6 69-70 <br />`:7LTD3e 1?'AL SAMPLE .r'??^ ..xtp<<^: ^dC-:..r r 1) <br />I~I'i`DLY E^~ MEASUREMENT <br />1J_~iS 1 D PEAMR-` ±~ar ~r~. +~~+~*~a '~~tEl~ORT t?g T'Sr!~l~1. rRLT .4A P' <br />t FP'LUF;N' '"~~~: Yrtr.O REQUIREMENT ,. ~. r,.-:~t is ; :11 9; )( F ! •'/' <br /> SAMPLE <br /> MEASUREMENT <br /> - ' <br /> REQUIREMENT ... ~-~- - ~ <br /> SAMPLE <br /> MEASUREMENT <br /> ~PEPMIT- - - "~ ~~~ <br />.~. - <br />;~ <br />j <br /> flEQUIREMI"NT .. .. - ~ ( , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIt" _ j <br /> REQUIREMENT ~° <br /> SAMPLE <br /> MEASUREMENT <br /> ~ ~ " <br />~ I" <br /> REQUIREMENT ~ ~ -- <br />" - I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - -' <br />~'.~ `^ t <br /> REOUIREMEN7 - ~ ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ - <br /> REQUIREMENT >- ~ ~~ - ;~,~=i ', . <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />M <br />LI <br />R <br />TH <br />F <br />RM LAW THAT I HAVE PERSONALLY ExAMINED AND <br />TTED HEREIN <br />AND BASED ON MV <br />AT <br />N <br />UBM <br />~ TELEPHONE DATE <br /> <br /> <br />P.IchRrd Mills <br /> <br />l til AM FA <br />I <br />AR W <br />H <br />E IN <br />O <br />INQUIRY OF THOSE INDNIDUAL <br />THE INFORMATION, I BELIEV <br />ACCURATE AND COMPLETE. IO <br />I <br />; <br />S <br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />E THE SUBMRTED INFORMA710N IS TRUE, <br />I AM AWARE THAT THERE ARE SIGNIFICAM <br />I <br />RMATO <br />NCLUD <br />THE _ <br />~~~/rJ/ <br />r~~ <br />% <br /> <br /> <br />7O-STO-27I2 <br /> <br /> <br />~ <br /> <br /> <br />~ <br /> <br /> <br />~ <br />1 <br />nnager <br />Fnvironrlenta PENALTIES FOR SUBMITPN N, I <br />ING <br />G FALSE <br />NFO <br /> POSSIBIDTY OF FlNE AND IMPR ISONMEM. SEE 13 U.S.C. y 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL E%ECUTIVE <br />TYPED OR PRINTED meximum~pme between 6 m~wrtN end 5lavar j~ `p ~ f10~ ~ ~ OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />COMMENTS AND F>(PLANATION OF ANY VIOLATIONS (Hererence err eaacnmen(s here) <br />i~fT LF:A -i.; ')LT''S LI`TT e1IPFU c')~ >i7Y4r 7':Nr ?1hC-rp :^T.•q r_-vr_T, 1,?e nr roe c?o •'TA CIt O)ITV~ njT- )• <br />1 Tr,` , •r ~ rCn•n 1T n• n <br />:4F'6S F' ~4AA g4~nL" rtu1LT`i[S octffI?F;I IT' 7T5[HL4 gHc'y j ry^c-~~r,1. .~•. -L.. ~. t. 71 t, Tf14"-T. <br />~T <br />EPA Form 3320.1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />~n?1:/oAJ1u17-1523 1 <br />