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<br />PERMITTEE NAME/ADDRESS Qnclude Funlim Nnme/Lorarmn /DiBrrenrl
<br />NAME
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<br />~7±i STATi' fIIGdLAY 1!
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<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR;
<br />(1-I6) (O- 9)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM U9 Q7 O1 TO 00 09 3~
<br />(1021)~~2Tyy131 (1415) 26~1]J 2819) (3031)
<br />Form Approved.
<br />~ I r. O ~ OMB No. 2040-0004
<br />Approval expires OS-3T-98
<br />(511 Ei~ Aw}
<br />?. TRYL09 PO!:C' '."0 TAYLG~ ,:i-F:4k
<br />NOTE: Read Instructions before completing this form.
<br /> (3 Card Only) QUANTITY OR LOADINGS ~ (4 Certl Onry) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-6T) (38-45) (46-53J (54-61) EX OF TYPE
<br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
<br /> ffi2 ml (64-68) 69-70
<br />{':. SAMPLE aagaa# lX pr: ,;: r~r.: J;~:k^•:r ~ ( ~~}
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN
<br />AND BASED O
<br />M / ~ TELEPHONE DATE
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<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON ,
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<br />SIBLE FOR OBTAINING J,
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<br /> THE INFORMATION. I RELIEVE THE SUBMITTED IN
<br />ACC FORMATION IS TRUE, 1~!~
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<br /> URATE ANO COMPLETE. I AM AWARE THAT TH
<br />PENALTIES FOR SUBMITTING FALSE INFORM
<br />TI ERE ARE SIGNIFICANT
<br />N , r~~}•N/ •'1
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<br />, INCLUDING THE
<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE to U S.C § t00t AND 33 U S C.-
<br />SIGNATURE OF PRINCIPAL EXECUTIVE ~^T
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<br />' TYPED OR PRINTED 4 t3t9 (Penettres under these statutes mey mclutle litres up ro St0,000,entl or
<br />maximum imphsonmenr of barween6monlhs ands
<br />ears
<br />) OFFICER OR AUTHORIZED AGENT R
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />. CODE
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) ;
<br />~i;'CLrP.!;LF S0L7DS Li.'IT rt:PLIF; OvLY IF <=l0YF,24H° 7RE;CIP EYENT I~ CLAIri:T. IF 4'3r.)Z1F ApPRCVP:L :;Y N~;C*,
<br />'P_.S L IPON UNIT:, .ILL E:OT 9c APPLI?9 TO fi£POPTFD ~'AS'IP.EM.!'YT'S - SEF: I.A.2, pG.._x~-d~fR BURUEf~ OF PF•~~F
<br />tEPA Form 3320-t (08-95) Previous etlitions may ndl be used.- - - - - -'(REPLACES EPA FORM'T-40 WHICH MAY NOT BE USED:) - - -~ ••'~ ~ """ •" ' _ - ~ " PAGE OF
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