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PERMITTEE NAME/ADDRESS (7nthrde Faoilily Name.~Gooation 7 D$eenU <br />NAME <br />rLiLn.YJ CnAL CC~FANY, L.'. <br />ADDRESSC7LOd}'r) ..°.I".F~ <br />5711 5'IATF' !1IG!iLnY 1.1 <br />FACILITY ~FFRF.F: CC P1E•U1 <br />LOCATION <br />n TT4: ,/• P. NA4P0'i, G£4 C.°F-I. `^A~A(:Fu <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />OISCHA61GE MONITORING REPORT (DMH} <br />(t l- 91 <br />rnn nn r,q ;,~ nn] <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR... MO DAY YEAR MO DAY <br />FROM Ra-07 O1 TO Ct) 09 ~C? <br />(202t) -°(22;23) (?~25) (26 P]) (PB-291 (3031) <br />Form Approved. <br />OMB No. 2040-0004 <br />'~ I y C" Approval expires 05-31-98 <br />~SLR~ N~~ <br />LOAitC':1', ;rDI P05D Ti! 9IL5Oh' Ci: <br />NOTE: Read Instructions befo a completing this form. <br /> (3 Certl Only) QUANTITY OR LOADING fir,. (4 Cerd On/y) QUANTITY OR CONCENTRATION NO. FREgUENC SAMPLE' <br />PARAMETER (4fi-53) (54-61) ;~-= (38-45) (46-53) (54-6/J EX OF TYPE <br />(3237) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 162-63) (sa~s3)S (69-70 <br />~- T:, F'.. .t ~A= E SAMPLE Rteo~C4 ~ np~ #C: ix `410 (: '.r (x 44 YT .; :~ (I!r •.:• <br />S T Wit: A 1. MEASUREMENT <br />'~('Ah 1 U l~~ PERMIT rpuL"?44 ~ ,,~. j F'!;=1 ~t~*3 •gbOll%+b 4%iilft%=t ~ .hh'' i t:~YLF 7I5~lAT <br />' F'kLL'F.' i G~.O;S pnT•~i~ REQUIREMENT ~ •Y NO=0 - ~~ z:Yn,;; <br /> SAMPLE <br />~~' <br /> MEASUREMENT ' <br />... LMY <br /> PERMIT ~ ` <br />~ <br />~ <br /> REQUIREMENT ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT e~ <br />- ~'~ <br />n <br />' <br /> .,~ , <br />y~ x <br />~ <br /> <br /> SAMPLE <br /> MEASUREMENT . <br /> PERMIT - Y ~'' -~ <br />< <br /> REQUIREMENT `~ ~z „_ <br /> 3. w <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c. .'. .ft`" I ~'q. <br /> REQUIREMENT 1 ,F • <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT u'' - <br /> REQUIREMENT ,y}. % ;-- - - <br /> SAMPLE <br /> MEASUREMENT ' <br /> PERMIT " <br />~' ~' <br />; ~. <br /> REQUIREMENT ' <br />NAME/TITLE PRINCIPAL E%ECUTIYE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT 1 HAVE PERSONALLY E%AMINEO AND <br />ATION SUBM <br />TED <br />RE <br />' TELEPHONE DATE <br /> IT <br />HE <br />IN: AND BASED ON MY <br />INQUIRY OF THOSE INDIVIDUALS IMMEOIATELV RESPONSIBLE FOP OBTAINING <br />THE INFORMATION. 1 BELIEVE THE SUBMITTED INFORMATION IS TRUE. <br />i <br />! <br />' <br /> <br />~ ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING THE ' ~ ~~ <br />, <br />~r r/'~~ <br />' <br />~ <br />T , f <br />' ` f. r ,~ ~,., " , <br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U S C. § 1001 AND 33 U.S.C. ~ SIGNATURE OF PRINCIPAL E%ECUTIVE ~T O ~~^ ~L.no h n / ] .~ ~. <br /> <br />TYPED OR PRINTED § 1319 (Penalties under these statures mey include Imes up ro $10,000 and or <br />maximum imprisonment of beRVeen6mon(lu'antl5 <br />eers <br />) OFFICER OR AUTHORIZED AGENT <br />~ <br />~R <br />NUMBER <br />YEAR MQ <br />DAY <br /> y <br />. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all attachments here) ~ <br />.:.TTLFnFL.!: SCLICS LI", I': AFT'LIF.'. ^_G1.Y IF C=1CY8r74!!H I'fiECIp P.>rL'NT Ii CLAI`!CD. IF' CLkYl1,~'~QPP.OYF:Lt RY NvC'Cr <br />:_-°;i ~ IAON LIf1IT5 PILL tiOT RF APPLI:D TO .~"~'POP.TEL +"EASUR~8LYT9 - SBE I.A.?, Py. 5 T(?IC"bUNGEDI GF PHV(1i <br />a _ __ _ ..~w~J- <br />EPA'Form 33241 ~ 08-95 Previous editions'rria n`ot be usetl ~ '~ ~ ` ~ ` ~ - - ~ " ` ' `" ° ' ' "'"~ ~ ~ ~ ~ "' <br />( ~ Y (REPL'1ICES SPA FORM T=40 WNIAY kTOT BE USED:) _ UOOZ 4 / 0~; ' PAGE ~ OF <br />