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PERMITTEE NAME/ADDRESS (InrG+de Fucihm Name/Location i(OrQerenq
<br />NAME CGLC.7YG CURL CUt'FA~.Y
<br />L.?.
<br />ADDRESS^O LG6Y+~ "'?Nc:
<br />57.f1 STSTE NI%1+W AY LT
<br />..~~}r Cc R7fu1
<br />FACILITY
<br />LOCATION
<br />..T:h: J. HAd":r l+, CL~+~ nL :+'. r'. ~[
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDESJ
<br />DISCHARGE MONITORING REPORT (DMq;
<br />R-i6) (n 91
<br />rnr`rD~THr nna ~
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM Utl;;.~ V~! cfl TO UG I!9 is
<br />(20211 22231 !2.1'251 (262]1 (2829/ (39-31J
<br />Form Approved.
<br />N I y ,i 1t OMB No. 2040-0004
<br />Approval expires OS-31-98
<br />F - FIAAL 'tOF'AT
<br />L^1DrTUT SELI PI^!;C TD WILSON CF
<br />a:x:•+ ti(' Bi5CH.4Ff:% ~ ~!rtAY,:
<br />NOTE: Read Instructions before completing this form.
<br /> (3 Card on 5)
<br />0UANTITY OR LOADING' ~~ '(4 Card Only) QUANTITY OR CONCENTRATION NO. FgEDUENC SAMPLE
<br />PARAMETER 3
<br />( ) (5461)"~,~` /38-45) (46-53) (54-61) EX OF TYPE
<br />(32-37) AVERAGE MAXIMUM U~S MINIMUM AVERAGE MAXIMUM UNITS
<br />r62 637 ANALYSIS
<br />(64 6B)
<br />(69-70
<br />• SAMPLE :?vr::}:r:x roona:r C*?#{+;}~: ( ~?)
<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND
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<br />E TELEPHQNE DATE
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<br />REIN; AND BASED ON MY
<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBIE FOR OBTAINING
<br />THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE,
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<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE tB U.S C 5 1001 AND 73 U.B C.
<br />I~gIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED § 1314 (Penalties untler mesa sleWfes may rnclutle nrres up ro 510,000 antl or
<br />maximum ~mpnsonmenr of beM1veen6monlhs andsy>;ars) OFFICER OR AUTHORIZED AGENT A
<br />cooE
<br />NUMBER..
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all attachments here) `4:;~
<br />~1-T°•L E'; I+L ~: `:n Lt':S LI!".IT AkFLI}:S Cr:LY IF <=10Y F, 7r1 P? FkF CIP P.VL'NT IS CLA.Ir°`T. IY CLAI"! AFPPC: ~C 1'.Y MQC ::,
<br />TSS E FRO;: LIMITS WILL '+." Pe~~AFFLI'~~ TU 4~POFTFC +!FASUFF:Y,}:NTS - Ssiti I. R.~, PG. 5 FCk 6UFG£t; GF PP.UCF
<br />EPA Forrn 99241 •(08-95) Previous etlitions rosy not be used. ~ (REPLACES EPA FORIiA•T-4U WHICH MAY NOT BE USED. ~ ^ ~ ~• ~ ~ ., ~ V ~ ~ V ~ J ~ PAGE ~ OF
<br />) 00023/OOOIt03-1007
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