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PERMITTEE NAME/ADDRESS (Include Facilip~ Name/Locmlan ifDlgerenq <br />NAME FiCKtT'ilhi FhCCES-Iki, LL'. <br />ADDRESSN E ~ ELK N I h E <br />1.111 EiREtiTGCCC CEI4.E <br />FACILITYEYANSYILLE ~ _.- jFl u7711 <br />LOCATIO:E57Gh ~ ~~C~C91 <br />A7'Ttlt kl TERRY, pAAACEh <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR; <br />fz~t61 !n- 9) <br />`ti°'m'-~ ERMIT NUMBER DISCHARGE NUMBER <br />MONITQEUNGQERIOD <br />V ~ D Y.:.i •~1'EA MO DAY <br />FROM TO - <br />(Y0~21J (26-27) (26~29J' (30-9D <br />Y <br />Form Approved. , <br />C I L C 8 OMB No. 2040-0004 <br />Approval expires 05-31-BB s ~I <br />~SUt:h SE) <br />F - fIIiFI LAhA: <br />ACUTE IIE7 TE~73AC FCF CCSA <br />NOTE: Read Instructions before completing this form. <br /> (3 Card Ony) QUANTITY OR LOAD. ' '(4 Card OnyJ QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (46-53) (54-61) (3B-45) (46-53) (54-6 iJ EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />!6z-uTl ANALVS/S <br />(64-68) <br />69-70 <br />LCbU STATE 48!'i! ACL SAMPLE ,;I :;:;;::;r.: ::;T>cC0 xq>y,r ,y;r„;" ( .:) <br />C L R 10 C A P h to L A MEASUREMENT -~ ""~• <br />A~",1:-i 1 U U PERMIT ~'"'~ >fe<o~- '~~~ ``a ; <br />.-, # EF- G 61Y FAE <br />t FFLUENT GRO$: YAIUf '~3.EOUTAEMENF CO~V RR }~~ : ,, <br />: <br />,. t'~ex~~ CE~I <br />LCbC STATNE 9bNf+ ACC SAMPLE =r44~~rr r: ~r.Y~r,. >~ ACGO+O 4tt[L~ ( ~:) <br />i• I PI B P R A L E S MEASUREMENT <br />:;.NbC 1 U U ~~ ~flF1~pT;; - '~ ~+ ~ 4oagofi ,a ao•r I G ;-,_~. p FE- S 1EIY FAE <br />E F F L U E h 'C C R O `.i : Y A L L' E Flfigil(A~A4ENT - x S *' ~ Ft R ~>~, .~ ~ C E A i <br /> SAMPLE <br /> MEASUREMENT <br /> PEFF~~IIIi ~ . <br /> , <br />fl~F11F~EMENT - <br />r <br />~"' - . - <br /> SAMPLE <br /> MEASUREMENT <br /> "-~-itERMIT - <br />~ <br />~ ~: ~ <br /> ~'(Ef~bIREM6NT - ~ 'T- „ <br />5~: <br /> SAMPLE <br /> MEASUREMENT <br /> P~RMrt ~ ~ `"'' - <br /> -}i~QUIkEMENT `"`: <br /> SAMPLE <br /> MEASUREMENT <br /> ~ <br /> R~EiUIREzMEF1T .' „ ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />NAME(TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO NALLY E%AMINED AND TELEPHON E. DATE <br /> <br /> <br />~. <br />~ <br />T(y <br />~Q AM FAMILIAR WITH THE INFORMATION SUDMITTED HEREIN; AND BASED ON MV <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />THE INFORMATION, I DEVEVE THE SUBMITTED INFORMATION IB TRUE, <br />~\ ~ <br />\]f <br />~ <br />, <br />. <br />(( ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT Jl <br /> <br />M (A ~ ~ r PENALTIES FOR SUBMITTING FALSE INFORMATION. INCLUDING THE <br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 10 U.S C. 5 1001 AND 33 U S C. <br />S NATURE O PRINCIPAL E%ECUTIVE <br />,~ /I •~1 ~.Ty~ <br />V r I ' I L~ <br />DO <br />~ O <br /> <br />TYP OR PRINTED 4 1319. (Penetties untler lhpse srelutes mey inclutle lines up to 510,000 end or <br />maAimum lmpdsonmerrt olSeMeen6months entl5yoers.J OFFICER OR AUTHORIZED AGENT A <br />C DE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />L <br />t <br />GUMMtN 15 AN V tAYLANA I I V N Uh ANT V I V LA I IUNS (HBTB/BOCe a// anaCD/I1BRT5 ^BTeJ <br />Scr. I.S.l, NF 5-7, tCF CETALLS CF TEST pRCCFLL'(F. ~Li•I:FT LC.C - 97ATI57ICAL FC1A1 L_°T]rATP YEICN ]~ <br />Le.THAL T:: SUS i:F 7E:T OnGANI5f15, AhC ATTACH ACU7F TCi;I~17Y TH9T SFFCh1 FCbn TC CCi. CCF]!9 Cf All <br />-rrL~ T.-.~~ T' ~~E N-T~ v o a <br />EPA Form 3320.1 (08-95) Previous editions maypot be,es>'d. ~ (REPLACES EPA FORM T-40 WHIC~1 MAY NOT BE USED.) C C C 31 / C C C ] I 1 - 16 i Q ., ~ PAGE I OF <br />I'.1:..... I <br />.~.~_. <br />