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PERMITTEE NAME/ADDRESS ()nclode Faciliry Name/Locerion i/Di$erenq <br />NAME CY i, :, ~) ~''%'iP~' C^F:'OV4T: 7Y <br />ADDRESS r~ r; L ;•. ~~ r ~ ~. ^ .. 1' (- : v <br />~ P.O. 1105 54 <br />FACILITY <br />LOCATION <br />A; 'Y: A;'y'~)F^ V?J1'9 Y.P. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) FDrm Approved. <br />DISCHARGE MONITORING REPORT (DMR~ OMB No. 2040-0004 <br />(zas) (+~~ 9) " .I •~ ^ Approval expires OS-31-98 <br />r ~. TIl r ~ M1(7 a cur v.+~ <br />('7'. <br />PERMIT NUMBER DISCHARGE NUMBER r _ ~ ~ ~, ! . <br />°~" . <br />MONITORING PERIOD ~ ~ ~ ('. r. r. T e r ~ ~ .~ <br />YEAR MO DAY YEAR MO DAY _ <br />FROM '7 ~ ~l TO z~ ~^ 1~~ ^r~- r-~ ~~.. ~.,tP~,. .. .: r.~ <br />lzazl) Rz-z3) !z4-zs) (z6zz) (zez9) (30J1) NOTE: Read Instructions befo Tnpleting this form. <br /> (3 Cab Ony) QUANTITY OR LOADING (4 CvlY Ony) QUANTITY OR CONCENTRATION NO. FREOUEN SAMPLE <br />PARAMETER (4653) (54-61 3B<5 46-53) 54-61) EX OF TYPE ~ <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNRS ANALYSIS <br /> (szaTl 64-68) 69-70 <br />~i 'JLLL'i~ T'"lrAf. SAMPLE -`r~`D~ r. .-. p.. ... ( rlt <br />'lii:5'JLVF:J MEASUREMENT <br />~,~' 15 0 ~ FEpMIT' IC+R¢R41 ;" ,##„a,~!1~- '• `` 119k~CP4 RSPOR! `JS~?tnMA2 TRL1' .4iR <br />~~ F' }' j r) r h T •: P 7 ; ~ Y <br />4 1 <br />!; REQUIREMENT • <br />s !11( <br />~~1 <br />} <br />y ~ ~" 1~ <br />C X ^ ~ ' <br />, <br />. , .. . ~ <br />, <br />,. <br />- - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT-; - - -. - - <br /> REOUIREMENT - - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> AEOUI(lEMEIT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMl7 <br /> AECIUIREMENT - ~ ~ ,. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . ~ - , ~' .. <br /> REgt11REMENT ?`~>~ ~ %-_ <br /> SAMPLE <br /> MEASUREMENT <br /> - PERMIT ~ - , <br />- <br />~ >~r <br />~ <br />~ - - -- r i F; <br />' - <br />- - <br /> AEQUIREMENT ' Ss <br />- ~ <br />" <br />r !- ~ ~ <br />~ <br />, . <br /> - <br />, . ~ <br />n ~- , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ - <br />" , .n.~" ~ - <br />`~ - <br />~ <br /> REOUIREMEN7 ' ~ ~ ) I>': ~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO <br />AM FAMIUAA WRH THE INFORMATION SUBMITTED HERE NALLY E%AMINED AND <br />IN <br />AND BASED ON MY TELEPHONE DATE <br /> <br />Rirhard M14IIIS INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON <br />THE INFORMATION, I BELIEVE THE SUBMITTED IN ; <br />SIBLE FOR OBTAINING <br />FORMATION IS TRUE, / - <br />/ ~~ <br /> <br />' <br /> <br />/ <br /> <br />F~virn~mental !9anar <br />r ACCURATE AND COMPLETE. I AM AWARE THAT TH <br />PENALTIES FOR SUBMITTING FALSE INFORMATIO ERE ARE SIGNIFlCANT <br />INCLUDING THE <br />N I ,-~ ~ ^/ <br />97O-B7O <br />2712 ' \ <br />I ~ <br />a~ ~~ <br />N <br />'~ , <br />v - V ~ <br /> POSSIBILffY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 4 1001 AND 33 U.S.C. <br />' $IGNATURE OF PRINCIPAL EXECUTVE <br /> <br />TYPED OR PRINTED 4 1319. 1Pereie <br />et under mesa srefuras may Include Ones up b 510,000 entl a <br />maximum impnsonmerrt ol6eAUSen6monthe entl5 years.) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />~E1'7"LF.AS1."~ ;7Li.'3 Li"LT ;4[7:'~ F')Y ?lOYP~?7'ip n~v~-rn -1r:!;T_~cr• T.4.1~ n^. TYe r±p urr~,.~.cr..~NTi• nLr ^ <br />::AY'.ASF. G1.4P ~q`~.^!, '.' 4~'"LYSCS o!E':iii!!t°7 iP VISI~L~ SvDpS r4 ('^PfPV°0. ^P°^Lv °4~PT.T`1C TPC~atiC^'!T1'f^•- <br />• r. .'. <br />-~' r <br />EPA Form 3320.1 (08-95) Previous editions may not be used. . (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.) ft ~ ~ 1 7 ~ 9 4 ~ v 1 ~-? 5 ~ 1 PAGE t OF <br />