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PERMITTEE NAME/ADDRESS pwd+d. F«d,ryN~./(a.nm L/Dlp...n)
<br />NAME ~0'ri ~•[. h!I I)H'i ['-LL i; ~•'S :'A'iY
<br />ADDRESS hCiALoIU}. "I!`,,r .. .. ~ iJ~T v:, .`i
<br />t'.vs r'v~ I.a 1..1
<br />FACILITY
<br />LOCATION
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<br />NATIGNArPbJ,L11TANT9r$C~IMGE SUMMATION s1'9TfNf INPDESI~
<br />DISCHARGE MONITORING REPORT /DMR!
<br />11-f61 17-191
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<br />PERMIT NUMBER DIBCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM i7 (',ll ~~i TD ryi ~'h j~
<br />174111 l17-131 lI4151 /26-771 118-I9) !36311
<br />Form Approved. # i
<br />PO!ID E 70 COAL C~4~~No.7oao-oooa 7-
<br />d rove! expires OS-31-98
<br />('Ub? 4C) 113115
<br />• - FI SAL
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<br />NOTE: Rasd instrucliom befofs Lr latlnp this form.
<br />PARAMETER l3 Grd Onlyl QUANTITY OR LOADING !I Grd Onlyl OUANTITY OR CONCENTRATION NO. FREDUENCY SAMPLE
<br /> 106-53I !5461 138-151 !06531 15a-5/1
<br />EX GF
<br />TYPE
<br />l3I-37I ANALyBIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS l67d01 161-661 168-701
<br />t .1 SAMPLE ;, {::~::: ~: ,~. :i::: :;:.~ r ,.~.; ~,y;: ( i Z)
<br /> MEASUREMENT (j
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FA FY UNDER PEMAl7Y Of
<br />MIUM WITH THE INFO UW THAT I NAVE PERSONALLY E%AMINED MD~
<br />RMATION SUBMITTED HEREIN; MD BASED ON
<br />/ TELEPHONE DATE
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<br />` I A A / -~.C fJ ~ MY INQUIRY OF THOSE INDINOUALB IMMEDIATELY REBPOHBIBLE FO
<br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS /
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<br />A/ III~~V..//~" L /Tl..~,a-+-.--+ I AM AWME THAT THERE ME
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<br />SIGNIFICMT PENALTIES FOR SUBMITTING FAIRE INFORMATION _
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<br />I 1 THE POBBIBILITY OF NNE MD IMPRIBONMENT. SEE 18 U.B.C. F 1001 MD ]]/ BIONATURE OF PRINCIPAL E%ECUTIVE (/ /
<br /> U.B.C. F 1 ]1 e. lPsrWtlr. rrM« rMw mem. n,Fy AxA,d~ rvws ,e ro i 10,000 AREA
<br />TYPED OR PRINTED eM«mun,uni,wrh«x„NNW Nrwwn enxnNa end8yral ,/ OFFICER OR AUTHORIZED AOENT CODE NUMBER YEAR MO DAV
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Rs/srsncs s!/ sttechmenfs hare/
<br />Stl(Lee1JLa -iULIDB LICIT RPPLlt_ Ot:LY i% <=1VYi.,1u; 4 6;:iC:FITA'IC:+ F.VFL"C iS CLAIh!:~.. F': r.fIIT:'t.` !::
<br />u L;HLLN Ui: PiiGUF ~hG!1 He; •. UL~TING 6; :.IcF' F:iJ~" ::ETi L:.An L~ SOLIDS PFIHARY Li"ITRTIC t~~.
<br />Epp Form 3320-1 108-951 Previous editions may be used. IREPLACE6 EPA FORM T-00 WHICH MAV NOT BE USED.1 PAGE OF
<br />006l7/93C223-ii`. f.
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