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PERMITTEE NAME/ADDRESS pnclude Faci(iry NamNCocafion iJDi$erenq
<br />NAME THAPPEd f 5: .G, Is:'.
<br />ADDRESSTHAPPr:? ri'd~
<br />P, O. H'1' ] ,7
<br />FACILITY V
<br />LOCATION
<br />
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMA)
<br />^ PERMIT NUMBER DISCHA ENUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~~ I ''~ ~ :~ i TO 7 I J) I
<br />Fonn Approved.
<br />OMB No. 20460004
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<br />(SU3R Nr)
<br />. - ?IVAL
<br />pOHD TO :c:.T
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<br />PiFATT GL'LCF!
<br />'" '•~ UISCHARG° "0~
<br />A"NOTE: Read Instructions befo~e~pleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br /> EX of TYPE
<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS aNALrss
<br />(' + SAMPLE : ~ x x C ~ >k II+? ~. # 4 ...='.='k+"i'~ ( 1 Z )
<br /> MEASUREMENT -
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<br />.JLIJS~ TOTAL. SAMPLE :'"F%`^a :'t::`r.:;::: {r ,;,-,:ra,<{t ( 19)
<br />.l'1;;l EVDrD MEASUREMENT
<br />~'153D 1 J U - ":~:'pEAMIY- -#oi~A~xfi+ .:'•?:•~~?a~f~g~. ... ;F :~~ ~ -
<br />.:r'FLUdhT CHJ55 YALU -REQUIREMENT .. +.°' ii+
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<br />`i')LI D?, Stir TLEAHL~ SAMPLE ~:: :: r:':C;t C: '::: :: ~? / GEAR'#?~ ( 75) c
<br /> MEASUREMENT ~
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<br />- ~ r'LU£t:T GND55 YALU~
<br />REQUIREMENT
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<br />(lS F E) MEASUREMENT ) y i'
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<br />,.Y.'LUEMT GNOS~ YALUi 'REQUIREMENT ~'._'<.; ~, 11 ~ !5 ~ d`P.,
<br />.)iL AND iREASF' SAMPLE '. '`~^`
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<br /> MEASUREMENT /
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<br />•_5F'LUH17T GNOSS YALU' REQUIREMENT .tie
<br />L7., IN COYDUIT :),{ SAMPLE ( 03) '~''~=;`';: '`v~G~n h#~".~
<br />i'irtU T°.EATfi ~'hT i'Ln N'i MEASUREMENT
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<br />:;JLIUS~ TOTAL SAMPLE ~~'~{`^p{r =`-..,d*, p1,cr:r^ti` ( 19)
<br />.iIaSOLYdp MEASUREMENT
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<br />u ~REO'UTAEMENT ~'" r .
<br />.t. ; `" K ~• ,$ i
<br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER ICeNly under penalry o/law that this document end ell attachments were TELEPHONE DATE
<br />
<br />' prepared under my tlirer.Tion or supervision In accordance with a system tlesigned
<br />to assure that qualllled personneTpropady gather end evaluate the lnfoRnallon
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<br />W. Gordon Peters submitted. eased onmyinquiryofthapersonorpersonswhomanagethesystem,
<br />onsible for gaVredng Ne information
<br />the inlonnation
<br />ersons direttl
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<br />P=eraident/General Mena er ,
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<br />subminedis,trihabestolmyknovAedgaendbeliet,tme,accurate,andcanplele. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED I am aware that there are signifrant penalties br submitting lake inlorma6on,
<br />indudin the ossibili olfne and im risanmen[br knowin violations. OFFICER OR AUTHORIZED AGENT A NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION ul- ANY vww I IuN~ (rlererence an anacnmenrs nere/
<br />I'SS TDTAL INON. LIt1ITi •7I LL BP. wP.IYED~ AND SETTLEACLF, SDLIDS LI~1iY APPLZ ZD FOR <=107 R~24Hk'PRFCIP !iYF..'iT-
<br />SSE dUiiDcN OP PP.ODF REQUIREMENTS Ui:1N,R I. A. 3. ".'DS "7ONITORING - I. a. 3. OIL o ;;R£ASE - SEd I.8.1.(u).
<br />orm 3 -1 9) revlo s e I Ions may e u e ~ •' ' THIS IS A 4-PART FORM PAGE OF
<br />DD 137/DDD717-135D 1 l
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