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a. <br />PERMITTEE NAME/ADDRESS Qnclude Funlim Nnme/Lorarmn /DiBrrenrl <br />NAME <br />ADDRESSGO LOM yO YIR ~: <br />~7±i STATi' fIIGdLAY 1! <br />FACILITY " ~ ~ ~: j C~ r-` 1 r 4 <br />LOCATION <br />n TT';' .7. ~. 'I P.yr,Od, '_Ef: Y'F i~.L i?d SAGEF <br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR; <br />(1-I6) (O- 9) <br />rnn~~~.trT nTr <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 ~ ( ~~} <br /> MEASUREMENT <br />./ . ': l' (1 1 !' U PERMIT tP004m4 ' ~"'14rYr tP gnS+R tC 4'.t r~ , :m y , .;!IMMiIO#Sti [] ~ Q 4 E : Y L t ~i i j : 1; <br />rL'J r':•^' .,?I)c~ 1n:. 1't REQUIREMENT '~~?n:~ Y'~=~_, ~r y <br />~,_ *~ ' ttAxl ~''U" '~'I <br />'LI:"i, :'iTSL SAMPLE r::iCr:rcr- ;rfi4##4 #####'+X ( i-') <br />-t-_ PY;10' C MEASUREMENT <br />". ~ i U [r 0 PERMIT r>,rP i*€'?rlm~ tlDptlrO4rA •`~ AIOp ~''>:'#, - <br />'+; ~ Q f fi (' ? ~ . •i A ., <br />-Fi'; <br />U°''"! -:055 VALU'. REQUIREMENT ~~ ` pyr•It :"+ ; <br />.- <br />+D~E R~f N <br />DATLY Y <br />t'"/I . r <br />C f?I <br />, .:,,._ ~" i . t <br />. <br />:I-IJ~, ~CTTL!'A:!L! SAMPLE +xa4rxa4 ?##4R•".t :3d#CPIR ( ~-,} <br /> MEASUREMENT <br />f/', ~ , "! ti U U PERMIT 4SJL404iP ,'9tIpC?!{IIIS'Ip s; ` : • '" ''s` >'~p. pQXX <br />. Q, ~ ( k C!"/ ; R A ({ <br />~.FF'LUE'rT ~;N'7:;5 YPlJJ~ REQUIREMENT ~ - <br />-... r„-r x;`,~,.~- . <br />.. <br />::3OffA #Y$' OAILl,a1X 'L/L wOVTu. <br />~::1"~, 't OT:`.L SAMPLE .?z~rX#a Ot1##r: :t rA##paITP ( I~} <br />(F.~ Ft} MEASUREMENT <br />C :..C ~ j L U PERMIT 4t0e 9t@12rR : ~'#(M'1R~~ (rY,n;v #~~ ~; • ~. ~ ..'%'=`€-~• C NCEI ; r. A Er <br />rrL::F:',l .,Fi7]~ YALI;r REQUIREMENT <br />~ T1 r:+:M1 .:,''~ ,'. .:--~~~ .i1TG DAI.L*~i'D' !LG/L rONSH <br />JCL A`: ;; .-i!E45E' SAMPLE ~'+>,:re+x :;c :t #`X#'.rir`: K:S+pi4#Il~ glier:##,} <br />-{ 1 q ) <br /> MEASUREMENT <br />.t /`, I:1 1 U U PERMIT G's ~7ar.# #tr sSna* ., •a•: y0 lNIIM89# <br />10 x . <br />.i C <br />~1iYtN <br />~f.AC <br />. iFLUL.RT G?!C•55 YALI'F REQUIREMENT '~°''''- :~`'~"~ .;e- ~• ISIS7 ~tAX !~G/L " G'RDIT <br />f'L'7a, ;'i Cn!{(; qIT%i)h' SAMPLE ( rl )) ;poi##4O rrt S:R#'.: i. •rt:•u'n••~: 'r <br />TTi :1 [I T..")'A ^.'YFNT oL;, r{~; MEASUREMENT <br />SUii`J~ I C (I PERMIT flf:PC?TT i?EPOP?' #'?~ _' #09tOt01b #x}48#rk 4 +•'~: " '$yKLY IM57At' <br />FFF'L'J E'.+T G'N.v °i$ VALU` REQUIREMENT jOpA A.YF RAIL[ °x p[•r "'"1iS -.; {r f: <br />.'CLIPS, '"CTRL SAMPLE +3-'.,,~.;ry<: e::a-:«.~ 1#t+'-'A40 ( ],~) <br />ISM[?LYLP MEASUREMENT <br />J '!r"' I C' U PERMIT n.444r::# !t##7na ; nr,* 4 <br />e t:. A~p~R•4 fiFFORT ';!~ 'PRLY iP.AB <br />?FL11F.'i': GHJ55 V.ALUI REQUIREMENT ~ +.".•. •. _ <br />~¢~v~' -.:-3Q~A -A-YC DAILY Y.X `~.'/L ~-:'-, <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 <br /> <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON , <br />N <br />Y <br />SIBLE FOR OBTAINING J, <br />~ j <br /> THE INFORMATION. I RELIEVE THE SUBMITTED IN <br />ACC FORMATION IS TRUE, 1~!~ <br />- f ~ <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 <br />i <br />h ~ ~ ~ _ A <br />O <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 <br />'-7 7.1 ~f ~p <br />Q2-G ~ /,~. T <br />,l <br />/n w1 <br /> <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 <br /> y <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 <br />.:-~.:~ :. ooossioeeuos-IOO7 L <br />~_~ . .- <br />