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PERMITTEE NAME/ADDRESS (/ndudr Facdirv Name/Latanon JDi[krenr/ <br />NAME <br />ADDRESSC rI L.}~y!I Y..7li '~ <br />7I.i1 STrTTF. }IIG!!iiAY l.i <br />FACILITY .. ~ L~ F: ~ n Cn 81 fi 41 <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR~ <br />(2 t6) fn- 9) <br />rnr r1. tiT c.T nm e <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM DO 07 ~;.~- TO OC ~~ ±~ <br />(2021) (222J) (24-251bg, (262]) (2829) (JPJ1J <br />Form Approved. <br />~ I fl rl is OMB No. 2040-0004 <br />Approval expires 0531-98 <br />(SIi BP. ail) <br />STEF.°T`.A CI:L~Ei TC GOCC ~PCS Ck <br />NOTE: Read Instructions before completing this lorm. <br /> f3 card ONy) QUANTITY OR LOADING <br />~ a card Only) QUANTITY OR CONCENTRATION <br />~ NO. FREOUENC SAMPLE <br />PARAMETER (46-53) (54-61) ~ j (38-45) (46-53) (54-61) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UN1sS~ <br />ly ~ MINIMUM AVERAGE MAXIMUM UNITS <br />r6z-63J ANALYSIS <br />(64-68) <br />69-70) <br />"TI. F5`t °.~ :F SAMPLE ,;r:p!<otG7 ( "'L) +Y4~l+XfXP OC: {:hn:Y .. ,:}•~': <br />t <br />I/ <br />~~ I <br />y I SI• I, MEASUREMENT C " ~ I <br />': ;,r% L C f; PERMIT gSs+}4+OrtQt -:~~., S ~;=1 rX 4~l '~ •:.. DI Xfr,r$#tM #rk +!tn{: r. r ,: •Y r: y srvLY PI3Lr .6I <br />- f"!'L"~' Z r: •.75" YAl.nt REQUIREMENT •~~~~ }+n_n ~,y, ;~=- ;. r;p~; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - ' : '~ I ~~ ~y~.'>_. - <br /> REOUIREMENT - ~ - '-~~ °~~' ° ~+`~~ ~~ <br /> <br /> SAMPLE <br /> MEASUREMENT .,_ ~T" <br />g <br /> PERMIT ~ ~ .t~+M - <br />~ ~~ - - <br /> R~QUIREMENT - ~'~ z ~_° ~ - <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ;" <br /> REQUIREMENT ~I~ ~,.'~ ~ ,*"ti i. <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~~ " - <br />'^ ~* <br /> REQUIREMENT ~, <br />' ),` <br /> r. <br />i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - "' j ~•, - ,4c;,' _- , . , ... <br /> REQUIREMENT '+:i£'i. ° _ ,~ ~?" - - <br /> SAMPLE ~ <br /> <br />MEASUREMENT C <br /> PERMIT - -~~. ~ <br />~ ~ -~ <br /> REQUIREMENT - ~7= <br />{ ~y <br />, r:n - <br /> ,, __ <br />~ • <br />NAME/fITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF <br />AM F <br />AR <br />HE <br />M LAW THAT I HAVE PERSONALLY EXAMINED AND <br />AT <br />B <br />HE <br />D '. TELEPHONE DATE <br /> AMILI <br />WITH T <br />INFOR <br />ION SU <br />MITTED <br />REIN; ANU BASE <br />ON MY <br />N <br />F <br />N <br />T <br /> I <br />QUIRY O <br />THOSE I <br />DIVIDUALS IMMEDIATELY RESPONSIBLE FOR OB <br />AINING <br />THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IB TRUE, ~ : <br />I y~' / T <br /> <br />ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />PENA <br />T <br />S F <br />SUB <br />E nub ~- <br />G! <br />~ <br />1 ] k In <br />` L <br />IE <br />OR <br />MITTING FALS <br />INFORMATION, INCLUDING THE <br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE tB U.S.C § reel AND 33 U.S.C SIGNATURE OF PRINCIPAL EXECUTIVE 1' <a [' 4 r L..n C i) I !7 7 <br />_ <br />TYPED OR PRINTED 4 t3t8. (Penalties untler rnese statutes may rnclutle hoes up ro S10,000 antl or <br />maximum ~mpnsonment of beiween6monlhs and5yeers/ ~ 'OFFICER OR AUTHORIZED AGENT AREA <br />OpE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />GUMMtN I5 ANU tXYLANA I IUN UH AN7 VIULA I IUNJ (HererenCe all atCdChmeOrS here) <br />~`:"LFADL° ~'aLZG.° CI": IT 5"YLI".`< uSI,Y IF C=IOYAr2uHR "PE:CIP EYENT I~ T~LdI""L. IF rLA7-I A,~ROVEG°Y M~'C:1. <br />I'S:i ?r 1hGF LIC!ZTS Vi LL tiCT HE APfLI`'D TO RF:FOA?F.C !'~A51,%4EF"'NTS - SLE I.A.1, ?~. `i FOP, 9URCF.N OF PROOF <br />E~A'FOrm 3320-1 (08-85) Previous editions •may not be used ~ ` ~ ` ~ ° r(REPL/ZCES T=PA FORM'T=40 WHICH MAY'NOT BE~U$ED.)`• ` ' ~ •~ ' ~ ~ ` ~ ~ r ` ~' ` ~ PAGE OF <br />OOCOU/OOOU03-1007 2 <br />.~..: -.. <br />