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PERMITTEE NAME/ADDRESS (Include Facilirv Namr/Location jDiBerrmJ <br />NAME SEkP-CA CGAL CCCFItiY <br />ADDRESSDRAMEk U <br />HAYDbY CG Pl~ <br />FACILITY ~ d?'' <br />LOCATIONr1AYDEN CU E1630 <br />ATTA: G. tiUD FiHOilti, GESL NAYAGiH <br />NATIONAL POLLIfrANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />D15CHAR)GE MONITORING REPORT (D(MH;9J <br />ccocota~l 0 1 u <br />-`- PERMIT NUMBER DISCHARGE NUMBER <br />. MONITORING PERIOD <br />YE.4U'; ~~ MOe~r }DAY YEAR MO DAY <br />FROM ~~ti ('til TO UU UD 1 <br />(21121) Z=13 (2d 26) (262]7 (28-291 I36JI) <br />Form Approved. ' <br />C I k iJ H OMB No. 2040-0004 ` ~ <br />Approval expires OS-37-98 <br />~suae Ilo) `~:• <br />P - rZM11 ACUTT <br />ACfl78 Y1! 4ESTIIG fCE G11A <br />` ~-NOTEo- Read Instructions bet ~° completing Ihis form. <br /> (3 Card Onry) QUANTITY OR LOADINGS !<Cartl Onry) QUANTITY OR CONCENTRATION ~- .NO. FREOUENC SAMPLE <br />PARAMETER (46-63) (54-61J (38-46) /46-53) (54-67J EX OF TYPE <br />(32-37) <br />=AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM' - <br />g'UNITS <br />/~-671 ANALYSIS <br />(6q.68) <br />69-70 <br />LC~U -~TATYE 4tlNN AC1. SAMPLE "'~A`aok +:aan~ - ~• aaaaaa aaaasl~~. ~,~i3) <br />CdAlOUAPHYI4 MEASUREMENT • ~' <br />TArK3E 1 0 0 PERMIT alaaaso a>raoale ;A talb r .i#iiio ariilii <br />F EB- ~ EI 'ei/$" <br />EFFLUtkT GHQSS VALUE -REQUIREMENT ~ - ~ ~~` 1 ~~ . ~ 't$ =~ t'- <br /> <br /> SAMPLE <br />" MEASUREMENT <br /> <br />~r PERMIT _ <br />~. '.'- ,.„ <br />r*~" <br />~;y~z °~'+r G ~, <br />z.-;:" <br />~ x, <br />:a3 3L _ <br />"- a <br />3F <br />~ <br /> REQUIREMENT ~ ~ ` e ~' ~ pGf " <br /> SAMPLE <br /> MEASUREMENT <br /> <br />Y ~~ s~~ ~. <br />"nr' <br />~~~ 3 <br />"~' "t <br />`' +v1: <br /> "BEOUIREIv1ENT IA .+ <br />~wr <br />iS~ <br />~! k , <br /> SAMPLE ~~' <br /> MEASUREMENT <br />• <br /> -': PERMIT- - <"?~+. <br />• M. -,~, <br />r <br />~ ~+..- -': <br />' -REQUIREMENT - r ~- <br />" , _ <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> -REQUIREMENT ~. ~ ~ ~ - - - <br /> SAMPLE <br /> MEASUREMENT <br /> ' <br /> -REQUIREMENT '.. - - _ - 1 ~, <br /> SAMPLE <br /> MEASUREMENT <br /> ° •-PERMIT` • • ~~ r ~ - <br />~ -. <br /> "REQUIREMENT: `;, : `~ ~ ~ •r'' _ <br />NAMErTITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO <br />ATION SUBMITTED HERE NALLY E%AMINED AND <br />IN <br />AND BASED ON MV TELEPHONE DATE <br /> ; <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br /> THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION I6 TRUE, <br /> ACCURATE ANO COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />PENALTIES FOR SUBMITTING FALSE <br />NFORMATION <br />NC <br />UDING THE <br />~ <br />^ <br /> I <br />, I <br />L ~/ <br />V 0 ~ <br /> POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF PRIrCIPAL E%ECUTIVE (/t <br />TYPED OR PRINTED maximum~mnn'slpnmern plDaM•een6me~r~~~5urle hoes up ro 510.000 and pr <br />ears) OFFICER ORA DRIZED AGENT A <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> P Y CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />SEB PART L -.4 FOH CE7AZL5 CF TEST PdOCfiDUhE. AE {CF.T LCiEST DILUTIClr (}~ EP FLUEaT) ~H]CH IS LFTHII 7C SOr'F <br />OF TBS? QP.GAliIStiS (LC°U) AdD ATTAC9 ACUTE TCCICITI TEST AEFCHT FCHC TC Dt1A. CCFLES CF ill IifCilIATICY <br />[.Ilea or ccu~ ~n an• ' <br />.EPA Form 3320-T (08-95) Previous editions may not be usetl. <br /> <br />_ ... ~ (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) <br />- ~}~ ~ ~ <br /> <br />~' 2 PAGE ~ OF <br />