<br />PERMriTEE NAME/ADDRESS Qwrii iwYrryNee/lermar l/DIOe.r,q
<br />NAME CYi':.~_ : +: ~. { -_ _ ..- .
<br />ADDRESS . .. ' .. _ . , ~ ... ~ ..' , . . ... ..
<br />FAaLm
<br />LOCATION
<br />NATIONAL POLLUTANT DI9CNAROE ELMINATION Sf9TEM //POE$1
<br />DISCHARGE MONITORING REPORT (D R1
<br />C ~~. ~i7%1 `U (:111 .',
<br />PERMIT NUMBER astNAADE NUMeu
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM L' J 1 ~: ~~: L TO J V S i
<br />~a.;Js
<br />:,.;UTT
<br />NOTE: Rud Irlehuetlotr E~for~ compbtlnp thb form.
<br />PARAMETER QUANTITY OR LOADING
<br />puality or Concentration NO• mEDUENCr SAMPLE
<br />
<br />E op
<br />PE
<br /> X AMAIYSIy TY
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNRS
<br />1 ,i SAMPLE ~. ~~#:X'k7 ;..y;t G'.cv Q##~=:::: l 1'%)
<br />~
<br />;1 L :~. c:: li Y E H A d L ~, MEASUREMENT U ~ (.{ ~ p ~7 ?j ~ ~ ~ (~r1{,.
<br />v ,: l.~:i 1 0 J .~:. PERMIT .. ~~- .:.riLQe^>~#~ ~. ..~:. fi rF:~Kt e}4 s .',c:1;= ~: .Lta''K'..X~;x ~t<~~. e~if~~
<br />1. ..k~~~ `y.-;.:.i:: ..
<br />
<br />e ., P.'11bEE
<br />
<br />~ klt6
<br />
<br />m
<br />r'L.:r.,.T GHUSS V. .J: :REOUIREMEH7: t#~xu 3OUl;et'G :R.;r:~.....Y hG/L N. ;;1,FTH
<br />:;. L'i ::K, PUTEN'P Ir Li 'i SAMPLE n##"'c## ###### #Y~:=### ~ ( ],9~
<br />'- ~: .; ;,V LD MEASUREMENT ~ LF]r~~ `,~
<br />~-l.J ~ ~ I~~L) ~[~
<br />,. _J:li 1 U U :.::..;PERMIT::~,;: '. ~91CIOI.#Of.'. ...: Y;:ruu+71, :, .### ~ #fix:i:xY ~~ ~~RkP!SE
<br />'~":~:
<br />~ ~:;R~F~.Tw~ka~~
<br />~ ~ ~ i:Ei~E/~ GRI-[y
<br />...?LV!:ST li.{(D$5 .: Ii ;REQUIREMENT,: ..:.~.::'~~:~~ ~-~~ ~ .:~~. :~~. ~~~: O### .
<br />:
<br />]0'La A~~.b~Y'G .
<br />.
<br />~:'~`?$S~`:'Y :i!k, ~' MG/L ~ ~iA~C126T FH . .. .
<br />r?~.H, P tlT'_..,.LY
<br />~ SAMPLE c;_:~:x-::: . qtr### =s##rC# ( 19)
<br />~.1~:+:LY t1i
<br />~~ MEASUREMENT ~~ OQ~ ~
<br />D , CD's 1~ Z/31 ~~~
<br />~~.1J~~ 1 7 ~IQ ~~-:;.PERMIT ~ ~~ ~~~u=J'-:~~3fi:~' ::.:0:~'>~~e?.#' .' .1;:::. o'f'!,1#!A~~~I~.~,'~':. .'i.'i73 ~ Gf~a££/ Cfi~AE
<br />YL:ZdT ;: dGSS YALUI REQUIREMENT F'#tc.`. 3Ga;k .AY[: ~ .:.IIT :!i;; L .S?S p'Tfi
<br />?i '.AGA9h; $!'., T_ITAL SAMPLE r~:~:0#3 ##Fr:::; r. ~. ::t-#:p:~'r
<br />( 1 ')
<br />6/JtP,
<br />It.-c:,v~H:, I.... MEASUREMENT .5~~ r7i~ Ol ~
<br />l'7 ,~~,a-a'
<br />11iLJ 1 ~, U ,:!PERMIT.:. x;;m.,.~::ts- {:ivy,:;r.71' c
<br />~ .>i#ri' *">rfik:=
<br />.r. FIAF.`ii'
<br />~ 'i.:.s'::.''::a
<br />..
<br />H
<br />' ~ f LUc'N ^~SJJS VALUI (REl]~REMENT ~~ :.~~ ~..: ,~
<br />~:: ~: ##W:' .
<br />... .
<br />34~.[r;~.. ?V~r; ~ ~.;>,:~~:.:2!;;!.
<br />+A ; C:,/:,
<br />e....r, II. .::iiDUIT OR SAMPLE Fro~yp
<br />~ `
<br />-
<br />(LOf~F~ j 03) fra#t: ;:v ###,Y~s ~;:;~s:~ f
<br />I ~
<br />~ :.. THr:A ih L~4T PLI W' MEASUREMENT ('OAl
<br />irrlS /
<br />~
<br />Ib~bT11 n.1S ,
<br />([f I/~ r'~
<br />'1t ~Yl
<br />'~:,: `'IU 1 U U :.:PERMIT.:~.. ~ :~. flB~.L?r'.1?~T ~
<br />
<br />: ::~. k£: 2L'.i~i.'~'. y~i~„#~'?~;: ~~~!I~#r.,..u:.::: ~
<br />
<br />:;.
<br />' .. - ~t,aKL E+STA'
<br />,
<br />
<br />(.'dr'C GiiUSS YAL.i
<br />
<br />. :REQUIREMENT:
<br />.:: ,: ;.:::~ .
<br />~Dwt e.~l:G :.
<br />i'AT:hY• i7X
<br />N.':J ... .
<br />
<br />;
<br />.
<br />~
<br />
<br />
<br />:
<br />
<br />
<br />~~ .
<br />: .: '.:J uREASE SAMPLE #3#G## ( y4) ###?#4 :::,c X;yt# :c .: Rr:#;'r
<br />_~ A L MEASUREMENT O 0 '~ 1 1` "•i1~4L-
<br />i~.'I~.b 1 U 0 :.:.~PERMIT~.. •.-...,. ,. r,<.
<br />,..,..,_' -
<br />~ ..... .. ,..
<br />c5=1 ...
<br />#Pk.lfi>Q#•,•
<br />s>%41#4:~.:
<br />rs[:.«°«a .
<br />s~:':?
<br />V4 ~Lt I U
<br />V 5 kl
<br />-: LUENT GROSS VA;.U ~REnuIREMENT. . t:>laST t9 A,1 (+U=U ua.
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ....~PERMIT'~ .~ . ~: ....
<br />~ ~ ~
<br />~ ~
<br /> ~fiEQUIREMENT~
<br />~ ~ .: ~. . .
<br />~
<br />NAMERITLE PRINCIPAL EXECITTIVE OFFICER 'nn,It• rr pr".,rol,. Ib,r unancumenl,ne ,u nr,rAmmunrn
<br />pnp,r.a .ne.r nT mr.rn"n "r wpn.bl"n In aaord.,re .Im ..nrrn eaE,.a TELEPHONE DATE
<br />Rieharei Vills le mart rbnl 9u,I1nN pen"nnM pr"pedT plbrr „M enN,le Inr Inf"rmabn
<br />wbMnN. paNenm~I,quI.TNNrpen"nwpenowwbom.n.pelMCTnrm, / ~ /J / ~ A
<br />N//
<br />~
<br />
<br />
<br />~ i"e•~Irental Paana
<br />i:r
<br />-
<br />or lbve pen"re elncrlT mpntlHe rer FnberlnE Nr lnf"rm,Oaa, Ibe lnf"rn,llon ~
<br />L
<br />//i /~r/ s /I
<br />c'0 F'?0-?7i2
<br />g
<br />r, wbmluNtr, lalbebvrarmTLm.kdpe,Mbeller,rnr.uavnra.bnrnpktr. ~- ~ --- ~
<br />/
<br />~ I/
<br /> I,m,.,nu,unrn.n Ypnlnonl prn,uln mr wbnlump nM inron:utlen, 610NANRE OF TINq-AL E%ECUTIVE i •U
<br />R PRWTED I,MUeInE lhr
<br />"dbIIIl
<br />or n,..,b ln
<br />rlwnn,enr r
<br />n
<br />I
<br />IN
<br />u A A
<br />TYPED O p
<br />T
<br />p
<br />w
<br />m.
<br />nE .
<br />,
<br />na OFFICER OR AUTHORIZED AGENT
<br />CODE NUMBER YEAR MO DAY
<br />COMMtrvIS ArvV Cnrl.nnni wn yr nnr •w~n: was lneromce en nucnmenra nvy -
<br />K_:di;NAT° LIMITS FOi; :5i r. „T'.i.LAOLr: SJLIuS (L'Ji; 'U') ;PFLY JNL- If ~= 10-Y~, <0-N;: Pri,iC7d EYE\T ;.,
<br />.. %.1tldG. SEE I.n.L, -~ ic, f'UR liUHL6tl OF ?n00F IiL4l'INi:"°t:'T5. ::IL r. J5F.ASE--SET FO'~TkO"t F, F/, F': ...
<br />EPA Form 3J20-1 (fjev 3/99) Previous editions may be used. 0 J 016 / `This ~ a14:pa14(Onll. PAGE OF
<br />
<br />
|