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PERMITTEE NAME/ADDRESS (lnclvde Faciliry Name/Locarian iJD~erenp <br />NAME <br />ADDRESSf;CIr,:.. T.iC;'}_L:D C}FE.n PiSk:, <br />L7V! ,.v r r . <br />i.:. :r f. ;:: .ti~:.e -.LiIr: 1..~ <br />FACILITYG:;A':L JIILC;:CM1 CC F.;`,~t, <br />LOCATION. <br />~F.Fy1::10.4IE CC'. ~1':.. <br />4."Ct. .)• ~':CYEE. CC'.~J:,Ti i1U [fr ~. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) FOrm ApprOVed. ~ ~ <br />DISCHARJGE MONITORING REPORT (DMA;9j :ACE OMB NO. 2040-0004 <br />~ ~ r U, A Q7 Y .(_ ~ F h ~ C) Approval expires 05-31-98 r <br />PERMIT NUMBER DISCHARGE NUMBER - E ~ F f L t l ~: t ;. <br />MONITORING PERIOD LriFCpiC 4F'i Tim"!]`C kCf CC7f <br />YEAR MO DAY YEAR MO DAY <br />FROM V. CL t;l TO UL ~'- .:- ~~'•' D,, iI:ChfkC: ~ '~~% <br />rzo zt?a. rzz-zit rz4~zst rzs~z» (zs~z9~ (30.31) NOTE: Read Instructions bafor omplehng this form. <br /> (3 Cerd Only) QUANTITY OR LOADI (4 Cerd Onlyl QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (46-53) (54-61) (3B-45J /46-53 (54-61) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM <br />S <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS ANALrSts <br /> ` rsaa3J (64.68) 69-70 <br />E'F:i C'r cRTF?E 7CAY SAMPLE - ~ .. OOyC~'~0 ~~~: >;L,, ~~: I ~_) <br />~.:~ .- I" E F E A L t 5 MEASUREMENT , <br />~ItC S C 1 PERMIT 440SI =:'A 4q;74x} ,} :r:, .:-y Ip -1~1~- OOG~rII >7 } kF~ ~ ~h]' 1 'CMECS <br /> ~ <br />.i; ! rG,"I •~!;T] k:E:.Le REQUIREMENT :; (.'.::,. H. <br />l~.~a ~ CEI'J ~I~L/ <br /> SAMPLE ~ ~, <br /> MEASUREMENT <br /> PERMIT - ~- <<r,'f= -'. <br />I <br />' <br /> REQUIREMENT ,,,„ , - t <br />=;~.: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ <br /> REQUIREMENT .r,. ~ "' <br />~' ~ ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />°-. <br /> REQUIREMENT ~;. ;'1"%' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT `~ t ~'.-',~~sur:'.=.:. ~ ~ I <br /> REQUIREMENT u'ti + - ' <br /> SAMPLE <br /> MEASUREMENT ' <br /> PERMIT ~ °' ~ <br />~ , <br />~ ; <br /> REQUIREMENT '(" '' <br />'+ ~ <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 MV TELEPHONE DATE <br /> <br />1I~-'(- <br />) (_ INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON <br />THE INFORMATION <br />I BELIEVE THE SUBMITTED INF : <br />SIBLE FOR OBTAINING <br />ORMATION IS TRUE <br />. _ <br />, <br />J , <br />ACCURATE AND COMPLETE. I AM AWARE THAT TH <br />PENALTIES FOR SUBMITTING FALSE INFORMATIO , <br />ERE ARE SIGNIFICANT <br />N <br />INCLUDING THE -~ <br />T V tJ J , <br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S C § 1001 AND 33 U.S.C. ~ SIGNATURE OF PRINCIPAL EXECUTIVE rF~ -' ~ i .,G / 1 <br /> <br />TYPED OR PRINTED 4 1319. (Penetties under these stemres mey include tines up ro SI0.000 end or <br />maximum impnsanmenr of barween6montns eno5yeers.J OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />OOMMENTS AND EXPLANATION OF ANV VIOLATIONS (Reference ell etfachmenls here) <br />.:-.. ....7 .... n.f~T F}CCE~Uk°_• FF4 F.E-GETS C} L=T}FLI!Y L't:i-~iYA11C6:i n] "::tFFC:"i Ci•C~'iF E }iFbCLCCTICM1 <br />~:rI7A'Iti.A.; A_' "TCyIC3TY". FpT LC..ESS kFFI A; 4kIC3 _Td.'I`T]CALLY c1CA1F C1Fk kF7trFEr 7E`_T C CCk'iFCi <br />Y.~Yi .. T.-'C I. ..TIin ~r-f1 rI'r. IrY Sr''n~~'i •.-r.... ~. •~.. ~~• i <br />EPA Form 3320-1 (OB-95) ~ Previous editions may not be used. T(REPLACES EPA FORM rt40 WHICH MAY NOT BE USED.)` ~ ~ pP,GE ~ `Ok <br />CG1dC/CCC11]-1F.:: ] <br />