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PERMITTEE NAME/ADDRE$S (include Facilirv Name¢acarion iJDi$erenr)
<br />NAME FICkETiiIRF fhCCESSIdG, 1LC
<br />ADDRESSN E M ELK N I N E
<br />1111 BAENTHCCC Cu1YE
<br />EYAtiSYILIF itd rJ7711
<br />FAClurv
<br />LOCATIONr L 5 T C N C C b 1 C y 1
<br />A'TTN: AL FEr,HY, tAnaCFR
<br />NATIONAL POLLU I wrv I uiJ(:HARGE ELIMINATION SYSTEM (NPDESf
<br />DISCHARGE MONITORING REPORT (DMA1
<br />R-t61 /n-T91
<br />C
<br />PERM T~IUMBER DISCHARGE NUMBER
<br />" MONITORING PERIOD
<br />ti
<br />Form Approved.
<br />M I NC n OMB No. 2040-0004 ~.
<br />Approval expires 05-31-98 5
<br />(SCc. .E) ,
<br />F - fIAII LACPS
<br />EL'NCEF FCAC 5/FCFGATC]FE F.IYEr
<br />t-:1 AC IISCtAFCI ~Q ~~'
<br />NOTE: Read Instructions before completing this form.
<br /> (3 CeN Onty) QUANTITY OR L
<br />~ .(I~fAMOnly) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46.53) (54-61f '• a (38.45) (46-53f (54.61)
<br />4 EX OF TYPE
<br />(32-37J AVERAGE MAXIMUM 'g`
<br />1#f,IfT ~~ .MINIMUM AVERAGE MAXIMUM UNITS
<br />f6as31 ANALYSIS
<br />(64-68)
<br />(69-70) '
<br />P R SAMPLE L b ~ ~"~ :` t, ry ~ C d +? ~ .)
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<br /> MEASUREMENT
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<br />GC4UC 1 0 U -.'PEFYN4T ~-: '
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<br />EFhLUENT GRU55 YALGf ~Q131REMEK)T -
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<br />SOLIDS, TCT'AL SAMPLE .A^rX'7 >?fi ;--',J+?.%+ •q>0~ 1 ]S)
<br />U S F E N U P. C MEASUREMENT
<br /> PH1~M17 ' ~ ~~ ' ~
<br />- .: G A C E / A i:.
<br />EFFLU'e!.T :;40`;E VALUE iiEgFIIREMENT' , %%;;o - ~#}`, .
<br />Nt AII. fG/I MCNTh
<br />3C LL U5, `.tTTLEA6IE SAMPLE ry'^''''~' '"""'~ '^;~ ~9 ( 4~)
<br /> MEASUREMENT
<br />UuSUS 1 U C )r~RM}i t;'• ~ F/ FAE
<br />~ttLJEhT GHO55 YALUF A~Q(lIREMERT :t-=
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<br />IFUF, TCTAL SAMPLE air:;nr,, +,::r,„;: ,: L y :
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<br />(A `_~ F Cam) MEASUREMENT l ~
<br />1'v45 1 G U PERMIT GO44 'Q>a40 p -0 ., ~.," ,•,,. ( •: / AA
<br />iFFLUE:iT GFi05S YALUE 'A~QUIREMENT %C• •.•
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<br />IL AN% GhEAS SAMPLE ~.+i ,''•: %`t,, is r, ><~i:q ;: Y,. %:~y~ ~;>b ( ]S)
<br /> MEASUREMENT
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<br />t.EeLUGtiT vh055 YAIUt AEgUIFiEMENT .. %G%'+ '° +' ,~`~. +r tlG/I ~f17 ~ .
<br />tLL,k, iH COHC IT CF SAMPLE 1 !'=) "'"~" 4at0Y
<br />'1 h ri U T li E A T >° E N T F L A A 7 MEASUREMENT
<br />~t;oSD 1 u U F!~RMIt 4Q: 6ff FT u >agaso ,% ~ s d ~;_~
<br />' l.91A
<br />ttFLUe~T GROSS YACLE A~QUiRE`FAENI` '3GIfr~ ~'I16, DAI.LN EfN. lGC ,,;Iry. , ;
<br />:7L eNa GhEAS SAMPLE `-~ 1 :04 .,. f,i; ;,:q~ q %~Kgtr,~
<br />Y i 'i U ,A L MEASUREMENT
<br />oV GhG 1 U U
<br />~ "P~RMIr. .- .q'. A F 8~.: E~=1 OIPb4L ~~.10 ;IO i69 -~AVill %08 kl I9U
<br />r.E"r'LUEr<T SHCS_° YALLE !~EGEUII~BM~NT ".: ', .(3X:S~1.-~R~,. AC=C .' .- tt~[ '"" ~".
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN
<br />AND BASED ON MY TELEPHONE DATE
<br />
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<br />L
<br />~
<br />A .
<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />THE INFORMATION
<br />1 BELIEVE THE SUBMITTED INFORMATION IS TRUE J
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<br />.
<br />ACCURATE AND COMPLETE
<br />I AM AWARE THAT THERE ARE SIGNIFICANT ~
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<br /> .
<br />PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING THE ~J~(~
<br />
<br />(vt ((N ti ~Y ,
<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 4 1001 AND 33 U.S.C.
<br />$ NATURE OF PRINCIPAL EXECUTIVE Q
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<br />O`er
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<br />TYPE OR PRINTED 4 t319 (Penalties untler mesa sretules may mclude lines up ro St0.000 erM a
<br />maximum impnsonmenrol0erwaen6monms ends yeers.l OFFICER OR AUTHORIZED AGENT
<br />CREA
<br />NUMBER ;•
<br />YEAR
<br />MO
<br />DAY
<br />OOMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here)
<br />JU U:iY AYIFnGE :°_ hIGFt.;iT E'CN7RLY. AVG. UUAIAG FEAICI, iir:}CFTEC CII E CFEASF. - ~EE I.z.7.[, F. 4. TS°_ t
<br />'EuT,L INCA LIMITS 4I 11 Ft 4AIYEC, ARC SEITLFAELE SCLIL:; lIY.I'f9 AFFIIEE FCr <=1GtF,i4hh FFECIF EYfA9-5FT1.
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<br />may nol be used. - ",(RE~t.ACES EPA FORM T-40 WHICH~A9' N,QT BE USED.) - ~ ~ 'PAGE
<br />,,x,~ :.. CGG15/GC 6771-1EiC 1
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