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PERMITTEE NAME/ADDRESS (Include Fociliry Name/Locanon iJDigerrnq <br />NAME j'~F`i)3 =h?'u^ (-n ::;r~vq^I'~y <br />ADDRESS,: p. ;Lr- "t1J h' ^~!r p!, ,•v <br />s .~ P.'O. -l"~X '•''. <br />c~~4; : ^~ yth75 <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR~ <br />12-16) (n- 9/ <br />n1 7 AA <br />^ PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ TO ~~ '%° ~~ <br />(76711 ($2-171 (24751 (2671) (1H-291 (7631) <br />Fonn Approved. <br />_ _ OMB No. 2040-0004 <br />~ Approval expires 05-31-98 <br />T .. .. q.. ',•1 <br />_ „ p>p• <br />nc~~v Sn _~aTy T~ dTI.TTn~7.e ...,~ <br />NOTE: Read Instructions bet a So plating this form. <br /> (3 Card Ony) QUANTITY OR LOADING (4 Cord Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (4s-53 ss-s1) 'A 3845) (4s-53) (5a-s1) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />ls7471 'watrsfs <br />(sa-ss1 <br />6&70 <br />JI?. AKp .;rF4:c SAMPLE r>r<r;r~~ ~ .r ,J) r,; ,~.. ,.., .. •: r:n-:" .C-~" <br />V I `~ U A L MEASUREMENT <br />:14:1~G 1 ~ 7 PERMIT `,dsa {~ :`, ' r'• FS-j ¢. e>rraaaee i"(ed4o~e x:_,, i5' A <br />}Fr!,(;c,NT (:DSc '14!.'!' REOUIREMEN7 <br />'t~Sfi-'~ ~ : <br />RO,=0' =w~: vrra <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT- <br />~- - .. <br />~ n"' <br />.~+- <br />~~ <br /> REQUIREMENT ~~,-~ • - - +~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - ~.~; : '. ~, - ~~ ~ 't4 ~ <br />~~` ~-, <br /> AEOUIREMENT - ~'-: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT '~ ' - F <br /> REQUIREMENT _ _ <br />- :.ii, I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT: <br />M <br />~ ~ - <br />- ~ <br />~ t:x(~ `: <br />' <br />'~ 1 ~~- -. I <br /> pNT <br />REQUIRE _ . <br />,i> <br />;; •- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - ~ 1 ' <br /> REQUIREMENT - ~'~ "c <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~~ -'~ <br />-t - i <br />` <br /> REQUIREMENT -' - - F, ~ ~{ r <br />p ~ ~~ ~ _~ : ! - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLI' E%AMINED AND ~ <br />n/ <br />~ <br />,/ TELEPHONE DATE <br />Richard Milli AM FAMILIAR WITH THE INFORM <br />INQUIRY OF THOSE INDIVIDUAL ATION SUBMITTED HEREIN; AND BASED ON MY <br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING / <br />~~ <br />~~) // ~ }^- ~~ <br /> <br />Environmental (Yiana er CCURATERANDI COMP 9L~EV E AM AWARE THAT THEREAA EDSIGNIFlCANt <br />F <br />E I <br />F <br />RMATION <br />INCLUDING THE / <br />~ "jj//~~~/ffq //C/C~-N!,' <br />~~ u~ 970-II70-2712 'O acG (~r <br /> PENALTIES FOR SUBMITTING <br />ALS <br />N <br />, <br />O <br />POSSIBILITY OF FINE AND IMPRISONMEM. SEE 1B U.S.C. 41IX)1 AND 33 U.S.C. <br />' SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED ss urMer mesa smtures may Inclutle Vines up t~ f10,000 entl u <br />4 1319. (Penem <br />maximum impnsavxnerx of sehveen8mandu entl5 years.) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here) <br />~F.TTLF.:1`%Lz S7L[1'< LI°7" ':IIVSB F'lr7 >(.')1c~:7'in n~rcr-Tp v7p•r+~_gcc_T~~~l~ T•r ~V~ r•le' r/cn(rTRPIVF!gTG~ CTI, <br />BRG1aF. „Hh@ ~~!^1.` Ay?LYSIS r?C.');1T.~c'') T~ PTST"L= gyc(•y TG ~.ooc.aro'1, ~pwr(,v `;4"n+T,;r TN`:*F.7CTTnN`:-T. .'• <br />3320-1 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-4D WHICH MAY NOT BE USED.) n n,) Z F ~ R n ~ rt 1 ~- T i ~ ? <br />PAGE OF <br />1 <br />