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PERMITTEE NAME/ADDRESS (lnrlude Facd+n' NamrlGorahon jDiBerenrl <br />NAME <br />ADDRESSCIJ LC ~ Y i . °.I ti'-; <br />5J'1 srAT~ P._c,d~A)~ I S <br />FACILITY ~ ` r K . F. .:' C~ ; I ` 7', <br />LOCATION <br />Y •"m .T I. Hn`7°f)A- ~11~~•Z 1. `iF I: G1: L-6 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DI$CHAR)GE MONITORING REPORT (DMR( <br />(1] 9J <br />r•nn nn cTC.t nn~ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY' YEAR MO DAY <br />FROM CO G7 Q~,TO I]C' iR 30 <br />(202t) (2223) (24T25~F~ R6~2r) l28~29) r30-311 <br />Form Approved. <br />OMB No. 2040-0004 <br />«T } ~ (' Approval expires 05-31-98 <br />F - Fi';AL h'~FA' <br />rYl••:,; •. J G I -. C f~ A F, (: f' ~~G tY i e <br />NOTE: Read Instructions before completing This form. <br /> (3 Cerd On N) QUANTITY OR LOADING ~(a Cerd OnN) QUANTITY OR CONCENTRATION NO. FREODENC SAMPLE <br />PARAMETER (46-53) (54-61) (3845) (46-53) (54-61) EX OF TYPE <br />(3237) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />(62 631 ANALYSIS <br />(64 68) <br />69-70) <br />. +J i,I.; .`'.r .r-'~~%'•= SAMPLE ryOr,,n,t'.x ^:r4rf4:I ,Y4~e~gIP ( <<+} <br />.: ~i S F F "~ L ~ MEASUREMENT <br />UU~!h 7- U U PERMIT Cfu+sGR5r O ~"R ~4^ nq :. •. <br />3~ - 7 <br />0 r <br />NCE/ ' <br />•n~N <br />FiI ii _` ~~0= ~ VRLU[ REQUIREMENT <br />^^„« -`" <br />b~r - ~"'~' r aw <br />..~1`~Tf~/'' tPG Y « <br />DA21.. .X <br />f G/L r.- <br />D.-,CH <br />' <br />I 'J ~' SAMPLE :f i~:;r7:a4 X+rC=O^r: nr„O=AR4 ( ;'1( <br />':% L ~' ' C „J i r e :~ L c MEASUREMENT <br />"_''lnl! 1 U O PERMIT riAr~~4O ' IiA00# ~ <br />~~`~' '~~+•~ ~Ip>m~ t~ T =. R$PCFT i RCF./ -4A8 <br />F P'L U',.'"" ~,~11 Yn Lllf REQUIREMENT .E~ <br />y~f~s _~ e:.^,•t ~- ~T A.~~()A x~j.` DAILY }tX il:/L D .`.CH i <br />.. .i., I\ ('G !. ii U'.. '.'. Fi SAMPLE ( F~-;) nr,: Xr001~ a¢:4 ,t+4 •`. ..:}v; •: <br />;' !}'! T ~ ;. A ^. ".: ;: T f L A !a MEASUREMENT <br />tiCi)` U I U U PERMIT R°Pd~'1' ~RrPORT iG rXRtFyyq•yy;, ~V>al+~ ~,` -'4Kefi31AA ~ : Y:++ r ACE/ fNST 4.' <br /> <br />!FFL~:F'.. (:}tOSS YkLi.? <br />REQUIREMENT <br />30CA AYC <br />DAILY 1'•X <br />"GD <br />,i~ s",x <br />.: <br />•:•:rd~r: <br />QISCN <br />; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - *y ~ ~,~~. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT •* ,:. - »'",",' - <br />-_ . <br /> REQUIREMENT ~ ~y <br />k~t `.'-t y <br />;i , <br />'~.~i -;' '- <br /> Y' + <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT ..,~~ ^, (,-n. <br />~~~ ~t <br />~`-~' <br />.. ,+,,,; ;", <br />~}~~-- .. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • ~: `r', -"I <br />: <br /> REQUIREMENT .ti .~ ~~r ~`~ a <br />... <br />Y <br />NAMERITLE PRINOIPAL EXECUTIYE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT 1 HAVE PERSONALLY E%AMINEO ANO <br />ATION <br />UBM <br />TED <br />RE <br />A ~ <br />~ TELEPHONE DATE <br /> IT <br />HE <br />IN: <br />ND BASED ON MY <br />S <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOP OBTAINING ~ <br />f <br /> THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS TRUE. <br />ACCURATE AND COMPLETE <br />AM <br />T ~ , r <br />' <br /> <br />i I <br />AWARE <br />HAT THERE ARE SIGNIFICANT <br />PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING THE ~ ; `. <br />r~,~ f~7 <br />' <br />`l <br />_~ ~ . )Yi J ~'~ ~. n , <br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1B U S.C 4 t W t AND 33 U.S.C ; SIGNATURE OF PRINCIPAL E%ECUTIVE ~7 ~r 1 ~1V ~ ~(erlJ Jn J <br /> <br />TYPED OR PRINTED § 13t9. (Penelfies untler these slalures may mcWde lines up to St0.000 and or <br />mex~mum mpnsonmenr of benveen6montns entl5 <br />earsJ -' OFFICER OR AUTHORIZED AGENT <br />CR <br />NUMBER' <br />YEAR <br />MO DAY <br /> y _ _ D <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) -. . <br />°rt'tIfO~I?;'.; R=aOI(iFM£hT° 'FF I.3.1.R, P4. 5. E'!ROEY OF PftOrJ~' RBQDINE`;L7ET5 - ,k:° I. A.~~n•~G. 4. <br />Tr. <br />EPA Form 3320.1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-00 WHICH MAY NOT BE USED.) PAGE I OF <br />a90~8/0 7~.. <br />