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PERMITTEE NAME/ADDRESS (include Facihry NamelLacaliun tfDi$erenry <br />NAME <br />:~LC~~C C:74L C~"FA'~'f, L.L. <br />ADDRESSC~)LOWY7 C::: i' <br />575: STA7E NIG`ILAY 1.3 <br />FACILITY ~~ ~ Y :: '-C 51641 <br />LOCATION <br />.l ^^ I J. n A ~! !' f i (.. F 9 r N :, 1. ~r 3 k R <br />FROM <br />IAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR; <br />p-I61 nl 9) <br />~~~ <br />i~N~rl 1.1 Rl~F <br />PERMIT NUMBER ~ DISCHARGE NuMeER <br />(2021) (22131 <br />I . ~. <br />t' - F; NAL <br />L~JAODUT LUOP <br />Form Approved. <br />OMB No. 2040-0004 <br />Approval expires OS-31-98 <br />~U~A~, <br />SFCI/uIL~ON CFE~; <br />NOTE: Read Instructions before completing this form. <br /> (3 Cartl Only) QUANTITY OR LOADING (4 Card Only) GUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (46-53) (54-61J (38-45J (4653) (50~61J EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />6z-631 ANALYSIS <br />(64-68) <br />69-70J <br /> 1 <br />"~; L A Nf. ~ ` : 1 .. r SAMPLE r,,:xfi4;tex • ~ 71 ~ <br />t , r,: <br />it frG'4 <br />rt'~'.I C: r.:-~: <br />,z ,:: rr ^I:?;: <br />'. 1 . '1 F I. MEASUREMENT <br />' w U h f, 1 U 0 PERMIT FR'aO+ROr <br />~rtr ~ c c_ <br />. ') " <br />+aIP40 +: <br />~>a*S>n#!i <br />Kclk'JlgOin ! <br />i•',k>t <br />I ' y.} ~/ <br />~~iR.Ct e <br />IJ(I~~ <br />• F i L L' i::: T A R 0'. 5 Y d L 0 i REQUIREMENT <br />ita0i~r~Rx <br />3:a=o „ ,_" "_ :';ri I t ; ~ <br />- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT '~ ~ <br />- '£" <br /> _ <br />6 <br />~ <br />~ , <br /> REQUIREMENT ° <br />~: 4 {`... : <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT " ''~' <br /> REQUIREMENT `~'~ ~a: - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -'~:~, ~'~ ~ '"'" <br />r <br /> REQUIREMENT ~ <br />}h _ ` ~ <br />' <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT <br />x tx~- <br />i <br />~ <br />' <br /> REQUIREMENT s <br />~ ~ <br />, <br />,. - ~- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ° ~ - <br /> REQUIREMENT <br />~ <br />~ } <br />t_~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ "+:;''` ~' - - <br /> REQUIREMENT ~ `T"•_ <br />; { <br />4 `^`,'~ __ <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSONALLY EXAMINED AND <br />ATION SUBMITTED HEREIN <br />AND BASED ON MY TELEPHONE DATE <br /> : <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR 08TAINING <br /> THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE, ~ <br /> <br />ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIGNIFICANT <br />PE <br />F <br />S <br />S <br />TT <br />G " <br />Q <br />~'~~ J ~ <br />T ~ <br />~ T t, (. NALTIE <br />FOR <br />UBMI <br />ING <br />ALSE INFORMATION, INCLUDIN <br />THE <br />POSSIBILITY OF FINE AND IMPRISONMENT SEE t6 U.S.C. § I Wt AND 33 U S C. <br />SIGNATURE OF PRINCIPAL EXECUTIVE //~~ <br />'i111 <br />Q 7 u. IY..~ <br />D J <br />1. ? ,. l <br />~ , <br /> <br />TYPED OR PRINTED 4 tat 9. (Fgnelues untler these s2Mes maY intlutle lines up ro Et0.000 ena or <br />maximum lmpnsonmenl of bebreen 6nronlhs antl 5years.) OFFICER OR AUTHORIZED AGENT <br />In A ~` <br />E <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />"E7T!.F'f:I:LP. SOiIUS LTi`IT i?PLI"c .`: C'~LY IF <=10YFf24yP, PS£C1F' £YEPT IS CLJ1I!1~'D. iF CLAI!' AFP9GYEP uY Wv~ L. <br />1ST G IHO:: LI!fITS MILL AO? u£ APi'Li"7 TO 'l~^r1F'"=L' r°.~5"R~'MLNTS - 5££ I.A.! P%. 5 FOR F.UHCEN U!' PF.L`CE <br />V ~. +J V+~I JflfJ CV• Yf <br />ESA •FOrrn 3320"1 (06-95) Previous editions may riot'be usetl.~ ` ~' ~ `!(REPL.I~CES SPA FORM TI40 WHICH MAY N'OT BE'U$ED.) ' PAGE OF <br />OOD52/000403'IOd~,.- 2 <br />_ y,~,. <br />