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v <br />FERMITTEE NAME/ADDRESS pw6isr6'ryNav/Loranan VD~...nq <br />NAME .. - <br />'ADDRESS ._ 1 ~ I ,. . <br />I'.. <br />r.~ .' i t `.. ~ <br />FACILITY .. _ <br />LOCATION <br />I. <br />- - ~- ~..~ ~a r~r_ -_ __-. _. _ _ <br />NATIONAL POLLUTMT D19CHMOE ELIMINATON SYSTEM /NPDESI Form Approved. <br />DISCH~R6E MONITORING REPORT lOM9/ OMB ND• 2040-0004. <br />. 1 ~ .~ ~ I ~ t ." _; Approval expires OS-37-98 <br />PERMIT NUMBER DISCNMOE NUMBER _ . . <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM ~- - TO . - - ' '. ~ - -~ ~ <br />/zo-z» rzz-z3i /ztz5i rz9n1 rza-zsl r3asrl •NOTE: Rud Intfuedarr beforelcompletlnp th4 fam. <br />PARAMETER l3 Grd only! QUANTTIY OR LOADING /4 drd Onryl QUANTITY OR CONCENTRATION NO. FlIEDUENCV SAMPLE <br /> lIS53 /54-61 38-/61 4653 51-51 Df <br />!32 371 EX <br />MALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS leas]! /51-5Bf !69701 <br />- SAMPLE .. i <br />~~ <br /> MEASUREMENT <br />r ~ PERMIT. ;:;: ;::::: ~ .....<.. ...... <br />. ~ r . ~ .. <br />. . ~ _ ~ . , , <br />. .REQUIREMENT ~. ~ .. ~ <br /> f y <br />L . ' :, f - , , - <br />,~- ~ ~ SAMPLE <br />MEASUREMENT _ .. .. .. ~ ~ t ~ ; t <br />..1 <br />~ <br />.u PERMIT <br />...,.. <br />,..; ... <br />:,,; v': <br /> <br /> <br />.. <br />.... <br />. :a': <br />~~_~:' <br />~ <br /> <br /> <br />. ^- <br />. r° ~.. <br /> <br /> <br /> <br />. <br />~ ]fs ,.` <br />`::/~ <br />. <br />_ <br />. .. .. ..REQUIREMENT . <br />~ . <br />~ . ;, ; <br />~~ . <br /> , <br />~. <br />- . ' ' I. i SAMPLE ~ r.~. ~ - ~ ~ .. ! ~ ~ <br />. <br />_• <br />MEASUREMENT <br />i. ~ PERMIT ., .. ~;t: s'TC•i'A":. ~`: `,. C", :?/ <br />\ F , ~,pEQUIREMENT ~ .,;I ~ ° <br />~ 'Y "CY <br />"' <br />: .. 1 r ), . a <br /> . <br />> ,. <br />~. <br />I <br />, SAMPLE :~~ ; .. ~ ~ , ~ . ~ <br />; <br />!. - <br />MEASUREMENT <br />1 <br />_ A .. ~ ,- ,. - .PERMIT ... .. .. ....... <br />.:..,.. <br />~ ~ .. ~` '. ~ r .. " `, .. •: / ., <br />_. r V . <br />~ <br />V <br />~ REQUIREMENT ~ r1., , ~..a :"- `:.I' ~..+'+,' ~ '• .~ <br />~ ~ - <br />~. a ;.~ ~ <br />r : "- <br />- SAMPLE .,.,....~ :. ,._.,_.,..~ - :t <br />( <br /> MEASUREMENT <br />. ~ <br />'~ PERMIT e. ~:~ ;;,~ ?r.: .. ,. ':i~Y,:.~, .. ., pat:: j. 1?' .. ;' , <br />' <br />_ <br />,,. <br />..~ REQUIREMENT ~ ~ ~ ._::. .. ... i:,.,.~ ... .,;.y . r, ~. r <br />, . <br />`. <br />~ ; <br />, , <br />~ SAMPLE ( l .. ... .. ' <br />r _ <br />- <br />~ <br />1 ~ MEASUREMENT <br />_ L C PERMIT „.,,'i ;:~ rn-t ,. _. 6c:.l...`.. .... .. .. r.; . <br />_!. _ ,t - • ,~ ;REQUIREMENT "~! 4~'r'~7 ,~ i L'.~'` ' ~ ~ ~ ' <br />,,. - F t SAMPLE <br />MEASUREMENT .. <br />1 <br />~ f I`. <br />~. /) , I <br />I` ~~ r <br />J :, PERMIT rr.,- -. ~.. C:':;:: ~: ~.: ?: `i Cf'I° ~1r ; I)r ,;' ., <br />1. , . ~ .; i , , 'REQUIREMENT. ... ~. R •. ~ A i :: ~ ~" +. ,:. i 1 ' i `. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I DERTIFY UNDER PENALTY OF NW THAT I HAVE PERSONALLY EXAMINED ANO TELEPHONE DATE <br /> AM FAMILIM WITH THE INFORMATION SUBMITTED HFAEIN~ AND BASED ON ~ <br />11 <br />1. l 1 ~1, 'I <br />~~ /. MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON9BLE FOR <br />I BEUEVE THE UBMITTED INFORMATON 19 <br />OSTNNINO THE INFOr1MATI0N <br />~ <br />/ ! ~ <br />~ , ~ <br />r <br />! <br />yy <br />/ TgUE. ACCUMTE MD COMPLETE. I AM <br />AWME THAT THERE ME <br />SIGHIHCMT PENAlT1ES FOP SUBMITTING FKSE INFORMATION <br />INCLUDING ~ <br />; <br />~° <br />. <br />I+ C I /~ Crl 1 , <br />THE POSSIBILITY OF RNE AND IMR1190NMENT. SEE iB U.S.C. 1 1001 AND ]] <br />610NATURE OF MIINgPAL EXECUTIVE <br />~~ <br />~ <br />J ~ ~ 1 / ~ <br /> <br />~ <br />~ 1, , <br />J I_. <br /> U.S.C. ! 1]te. lf1vW0Y. uMw sw.r Aamm. wMY /rt1W ISIF. IP ro f /O,OgD <br />TYPED OR PRINTED we.mvhxAn insrs+wwrr efatwrn snxneb wsFral OFFlI:ER OR AUTHORIZED AOEM COQ NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRe/erence sll attachments here/ <br />. , .. ., - - .. - .:. - c .. 1 .. - - - - <br /> <br />EPA Fbrm-3320-1 108.4 Prsvibue editions may bs us~ - IREP CEB EPA FO M T40 WHICH MAY NOT BE USED.1 PAGE OF <br />