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PERM ~ DRESS pnclude Faciliry Name/Locadon ifDi$erenQ
<br />NAME
<br />. ?. .Jy =~~% hH
<br />-'':N41'~ C~ °167.5
<br />FACILITY ~ '
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESJ
<br />DISCRARGE MONITORING REPORT (DMR~
<br />(2~16J (I]- B)
<br />^~. n 7r t ~ nn'r
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 9 a 0 7 71 TO ^'~ ^ ~ 7 ^
<br />/2(421) 82-23) (2F25) (2641) (2&19) (3031)
<br />Form Approved.
<br />OMB No. 2040-0004
<br />-~'~ ~ r Approval expires 05,31-96
<br />^ - °Tafi r~nl,
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<br />^'~NOTE: Read Instructions betor )plating this form.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (98-53 5981 (3B<5) a6-53 (5461) EX OF TYPE
<br />(32-3n AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />re2c31 aua-YSls
<br />69-se
<br />69-70
<br />LI+ SAMPLE -:'rSYC: Rt+}~;: .. ,..t:. .... ! ~7
<br /> MEASUREMENT
<br />UnonU 1. 7 n PE'RMIT.;.> .: a _M~- `~~~;
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<br />rFI'LUEKT :P'lg5 VA L'! ~REOUIpEMENT
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<br />`;'I!,I CS, '~.TTL°4'~LF SAMPLE ••t-PG70 tr;tktr R? I ~-)
<br /> MEASUREMENT
<br />UU',=lti 1 D 7 PERMIT R#41~" +,~ra~AF ~-. c•:., MO 'I:m~~.~?~1R'~ (} 6 M~^E~ ,!?S9
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<br /> MEASUREMENT
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<br />rHrl 11 T'1 ;'e Tr CyT P1 A'; MEASUREMENT
<br />Sa'I-~;) I p (! .PERMIT= ~liRPO$#- ~ :•°:~~p~~iR" Ae~M3l1d4L
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<br />NAME/TITLE PRINCIPAL E%ECUTNE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO NALLY E%AMINEO AND
<br />N MY TELEPHONE DATE
<br /> AM FAMILIAR WITH THE INFORM
<br />INQUIRY OF THOSE INDIVIDUAL ATION SUBMITTED HEREIN; AND BASED O
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING / - ,
<br />Richard MIIIs THE INFORMATION, I BELIEV
<br />ACCURATE AND COMPLETE. E THE SUBMITTED INFORMATION IS TRUE,
<br />I AM AWARE THAT THERE ARE SIGNIFICANT
<br />~ /J ~ ,~
<br />
<br />I ~
<br />(+
<br />(.'
<br />
<br />FfI VII'OIImPTtta) S.ta IlA321- PENALTIES FOR SUBMITRNG FALSE INFORMATION, INCLUDING THE
<br />POSSIBILITY OF FINE AND IMPRISONMEM. SEE IB U.S.C.51001 AN033 U.S.C. _
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />970- 70-i7i2 a
<br />
<br />TYPED OR PRINTED 4 1318. (Pereties under Ness stefurea may mGUde fines ap b Sf0,000 end or
<br />rrenmum ~mprisonmer9 or beM9enemOnflu ends yeen.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />GUMMtN I S ANU tXHLANA I IUN UH ANY VIULAI TUNS (RBlBrenCe al! aRaCOmBnLS nen3)
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<br />EPA Form 3320.7 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
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