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PERMITTEE NAME/ADDRESS (include FaciLry Name2ncanon i(Differenq <br />NAME <br />IF.hHFcB rll.:'wc, 1hC. <br />ADDRESS,. <br />~..drk'. :: '{. . <br />FACILITY C~ iti I V C C f 1 F 10 <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (OMR OMB N0. 2040-OOD4 <br />Approval expires 05-31-98 <br />PERMIT NUMBER DISCHARGE NUMBER c - F 1 A F 1 •" ~ ; - .L <br />MONITORING PERIOD F: N G 1 1 C 1 C .: C l a `_ C ~ C L I ~ i <br />YEAR MO DAV YEAR MO DAY __ <br />FROM C'C CR J1 TO CC C`_ ?1 ~~'_~ °L LI_°CS:AFCF J J t>ir <br />(zo-zl) (zz"z3) rz~-zs) (zs"zr) rz6~zsl l30-31) NOTE: Read Instructions before cSmpleting this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Cerd Only) QUANTITY OR CONCENTRATION N0. FREOUENC SAMPLE <br />PARAMETER (46-53) (54.6/j (38-45) (4B-53) (54-61) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />I6:-6J) ANALYSIS <br />(64-68) <br />69-70 <br />P .: SAMPLE ; c:.; r: _` ... , ~ r, :; , :i r, I t . 1 i <br /> MEASU9EMEN B~ 8, G' /~ z"~/Ty <br />OC4C0 1 U L t BEF{MIT ~~~~;~~ aX+c>D0~ _; ' E.` fi+in6bri 9.0 L fFK1Y DSITL <br />ff'LCEhT i,:i05~ Yn1.Lx R~f~71REMENT t.:::: f. b1t<U!' M t' ~[' :;, <br /> SAMPLE <br /> MEASUREMENT <br /> -~R~ <br /> RE4UIR~NIENT ... , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r pY <br />~~~ <br />" ~ - - <br /> REQUIREMENT '- . - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> - .~P~AR <br />~ .. <br />- r i.. (~' <br />fi ~ ~ <br />` <br />~ <br />" ". <br /> 131RE'MENT <br />RE0 - t <br />l =;;- ; , <br />--" ~ <br />~ <br />, . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ "s <br /> REQUIREMENT <br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERS <br />ATION SUBMITTED HER ONALLY E%AMINED AND <br />AND BASED ON MY <br />EIN TELEPHONE DATE <br /> ; <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />I BELIEVE THE SUBMITTED INFORMATION IS TRUE, <br />THE INFORMATION ~~ A t/_ /~~- <br />L ~ <br />/a• <br />~1~ <br />l,~rd 7~1 Peters . <br />ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />DING THE /- <br />~rl)_g ~y-~" 1 <br />(~( <br />~ <br />, <br />,=t loeaeTal K11.SCHr <br />L'CCS 1(1 ' PENALTIES FOR SUBMfrT1NG FALSE INFORMATION, MCLU <br />POS5181LITV OF FINE AND IMPRISONMEM. SEE IB U.S.C.§lOpl AND 3a US.Q <br />0 SIGNATURE OF PRINCIPAL EXECUTIVE <br />-- <br />TYPED OR PRINTED 0 end or <br />§ 1319. (Penalties under Inese statures may IncWde lines up ro Ef0,0 <br />maximum lmpnsmment or beMeen6monlhs ald5yaers.) OFFICER OR AUTHORIZED AGENT R <br />D <br />NUMBER <br />YEAR <br />MO <br />DAY <br />i~ <br />I~ <br />5 <br />OMMEN7S AND EXPLANATION OF ANY VIOLATIONS (ReTerence err attacnmenrs Here) <br />.i7 ~ 'IL'!Li 1BUfi 11P19~ yILL DL e6IVc.U~ dAL ::ETILIA:II- SCLiLL 11P1I .4LF1[~L F'.; C=it'.i, ~.t: rrCl1 ~YtP:- <br />6E tiUiSLCI. OF FkOCF FE~liI6E!':!/'IS uNLFEi I.A.3. FEF!i'I2%f N.DL'1 ;nnc A:I Pt?~L,•: ".. ;:1_'.'_ ',i Plot; <br />i ~,L ~ '~ 0=7~108~!§ o P vious ~~ ~ ~-- ~zp °c.. : =e`d. CES F -40 AINID AY NOT BE SED.(` ~ " ~ ' ~ ; ' PAGE _ OF <br />