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~. <br />P~AMFITEE NAME/ADORERS peMLi.:w~gN../Lecm/on UDI~G..v1 <br />NAME _ r „ <br />1 Y y ~ _ .- , <br />ADDRESS ., ~ ~ ., ± _ - <br />FACILITY r { ~ ~ ~ k r <br />LocAnoN` <br />- I f - i -. 1 <br />NATIONAL F'OLLUTMT DISCNMOE ELIMINATION SYSTEM /NPDES/ Forth Approved. <br />DISCHARGE MONITORING REPORT IOMRI ; - ~ ; OM8 No. 2040-0004 <br />' 1-161 /7-19 ~ - ~ 1 <br />-, ,, ~~ t r , ~• - r I ~~.~, ;, i ' •~- 1 ~ APDrovd expirer 05-31-BB <br />• PERMIT NUMBER DISCHMGE NUMBER - <br />~ / .. <br />- `I' -~ MONITORING PERIOD ' ~" ! <br />YEAR MO DAY YEAR MO DAY _ <br />FROM ~ ~ - :I r~ TO ') t ° . , ,, ~..; -, :. ~ ~-. ~• t :. : _~ ~ __ ~ :: r <br />,!~ ~'. (16111 (11-131 11475) 11&ZA u8-191 /36311 NOTE: Reed Inetructlar btae COmPletlnp thM form. <br />PARAMETER l3 G/d Ontyl QUANTITY OR LOADING /~ Grd On/y/ QUANTITY OR CONCENTRATION NO iREDUENCY SAMPLE <br /> /06'-53/ (546'7/ 36J51 /46-53 1546/ OF <br />131-371 EX <br />MAlvss TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS nT1-e!! /6{-661 /6A70/ <br />_ '.-:). SAMPLE .. - ~ .U' -', .~ ~'e9G ( i ~I <br />. MEASUREMENT / ~ / <br /> <br />~ / <br />~ <br />~ ( . <br />~. 1 (' PERMIT ..:;c:y ,': ::;=4:>;:>,: C ;:. +'`-••:pfi~? ~ ~~ a~f iLJC;: / :.i)~?f ):I <br /> REQUIREMEN7 <br />,: <br />T.1 <br />:C `, f'I~: SAMPLE .UV1: L-'% .VUI G~~Z. ~ ,•S~ ~r:p:y:::: {=:r .,v :: .:: i„: ;: I <br />r <br />, <br />- MEASUREMENT <br /> <br />,~ : ~ I i ~ C .PERMIT: ~~ 0.~1e5 u~o/7FfT 6=Fa'ekyn.:` ~<..,rY.: ..,_~~,~,~0. ~ .. 4::`.'~~,.V -E; 5'" 4`I <br /> REQUIREMENT ~ ~ ~ ~ " <br /> ... <br />-. i;.iF'.1 fi.'.~ F-~t:h~ SAMPLE ., ........ i::y .: ;; ...: o?..__._., , <br />r 3) <br />1 <br />. MEASUREMENT L 1 ~ 1 ~ ~ <br />u_ , <br />L ; , v 1 <br /> <br />:., <br />1,1 ,-,:) 1 ~ ..PERMIT ;;c r t, :}[a ~? ~~}~`~: (e ': ~;; ,.,+e f: ,~{: i):1 '1 ['')n. / t 7~:i! f'-i;u <br /> <br />..4 1 itt .REQUIREMENT ~ <br />'ai: <br />T ~. <br />ry~ ;'Y )~;-;'^. 1-'-,' <br />..n,. ~.:: <br />,r <br /> SAMPLE <br /> MEASUREMENT <br /> .PERMIT <br /> pEQUIFIEMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ... PERMIT <br /> .REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />• PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> pEQUIREMENT <br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER 1 cERn Fr uwDER PENALTY DF uW THAT I NAVE PERSONAUr ExAMINEO MD ~ ~~ <br />/ <br />~ TELEPHONE DATE <br /> AM iA MILIM W1TN THE INFORMATION SUBMITTED NEADN; MD BASED ON / <br />l <br />I +~ ._ 1 - I ~ r <br />4• MY INOUIIIY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTNNINO THE INFORMATION <br />I BELEVE THE 9UBMIRED INFORMATION IS ~ <br />/ <br />` <br />) , <br />TRUE. ACCUMTE MD COMPLETE. I AM AWME THAT THERE ME <br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING / / ~. L <br />. <br />( <br />i <br />' <br />P , <br />THE PoSSIBNTV OF RME MD IMPRISONMENT <br />SEE 10 U <br />S <br />C <br />f 1001 MD 73 ~7 ~ ~ ?-~% <br />- j ; <br />I( <br />A <br />.. V . <br />. <br />. <br />. <br />F 1J <br />IF\' <br />'M <br />l <br />e <br />h <br />F <br />SIGNATURE OF PRINCIPAL EXECUTIVE / l <br />~ ~j ~ 7~ <br /> F uW/ e <br />.~ mom. nMy <br />t <br />. <br />W. <br />cluM <br />iiwa W ro i/O,D00 <br />U.9.0. AREA <br />TYPED OR PRINTED en0umuinun hlpinnrw+r a/bnrA«remer.IAA rWeyrra/ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV <br />CVMMGNTS ANU CArLANMI IVN VC FNi VIVLNI IVIN.I. IReFeIOnCe ell eRecnmsnfv npB) <br />rEPA fam 3320.1 (08.961 Previous editions mey be used. (REPLACER EPA FORM T40 WHICH MAY NOT BE USED.1 _ ~ - - PAGE , OF <br />