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RERMITTEE NAME/ADDRESS Qnclude Fanliq•,vameiLoronon ifDiBerenq <br />NAME <br />iii 4h:i C,r ~i:C. <br />ADDRESS};Oit7 :rsL:."r"_~P CI°.En Yitii;~ <br />11CI' ::G:'L:, `.-: _' is 1~~'.r ., i;IiE ii:i <br />FACILITY `: k F: i 1. ,i 'J d C: I C tr C C ! `, i, c <br />LOCATION, <br />d'L'.! J. !.• :TL.4[1~ CC`•;GL~~1•., Lire. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (OMR; <br />(2d6) (1 ]- 8) <br />,ref ""rctiC f.Cl F <br />~eQERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR. MO DAY <br />FROM =' 4 C i. ~~ TO G C l i <br />(20211 ' (2223) l2a~25) (26-2y) (28-281 (30.31) <br />Form Approved. <br />OMB No. 2040-0004 • <br />L r+~ = Approval expires OS-31-98 <br />~~vkF VC) <br />F - f:?~P[ LIiY:r <br />~Oi J Cti CC~tl~fL [_'CtbC <br />NOTE: Read Instructions before completing this form. <br /> (3 Cerd <br />UANTITY OR eOADIN <br />) (4 Cerd Only) OUANTIIY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (465 <br />3) (38.45) (46-53 (54.61) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM <br />TS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />(62~6]J ANALYSIS <br />(54-5BJ <br />69-70 <br />UIL n~. I; F. I:ASc SAMPLE ~ '~ ~ ) -'~LOEb +5{=1 +h "7 •~ r;<c'< Z <br />~- .:. J .i L MEASUREMENT .~! <br />S' +G ~3/ <br />u4 `f,t i u PERMIT {A~Or?O Q Y ,__: dOp~ COtOYrA +7$tl¢CIC 'D ':~:: 7 47CI/ 7SUAI <br />~Ft LLt',I ~cri~°_ ~'6~C2 REQUIREMENT ZNS~ ~~~ rC-t, tCA7F <br /> SAMPLE ' <br /> MEASUREMENT <br /> PERMIT <br />• - ~" <br /> REQUIREMENT ~ - . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~' ; - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :. ~'+~ <br />~~` <br /> <br />REQUIREMENT . <br />_~ ,,;~;.. ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT °~Tt+ "; ~~ <br /> REQUIREMENT - <br />' <br /> ~. <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />' I CERTIFY UNDER PENALTY OF LAW THAT 1 HAVE PERSONALLY EI(AMINED AND TELEPHONE DATE <br />'/ <br />I <br />~ <br />ty( <br />S ~ <br />L <br />J AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON MY <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />THE INFORMATION <br />E 7HE SUBMITTED INFORMAT <br />ON IS TRUE <br />I BELIE <br />.. <br />: <br />. <br />Y , <br />, <br />V <br />I <br />NIFICANT <br />CC <br />R <br />RE <br />f / <br />- <br /> U <br />ATE ANO COMPLETE. I AM AWA <br />THAI THERE ARE SIG <br />A <br />FA <br />THE ~ <br />i <br />~ <br />T T' ~ 5 PENALTIES FOR SUBMITTING <br />LSE INFORMATION. INCLUDING <br />POSSIBILITY OF FINE AND IMPRISONMENT SEE tB U.S.C. 4 1 Wt AND 33 U.S C. /SIGNATURE OF PRINCIPAL EXECUTIVE : Q -G/V/ 1C! ~~ i <br />TYPED OR PRINTED mazimBOmlm~sonme ~a/beiwee 6meonlns antl5utle !Ines up Ip t+0,000 end ar <br />p years.) OFFICER OR AUTHORRED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />;'r. ;'LT:i. :'.Ur:'f KCYIFY aI;CC -ivLAF ?HIUF TC CC.°tIP:'iG :.:i~i::,i~:,~c:i-Fnri I.d.4~ F~ 1~. 1'.CA7FL1 P1ti116: t~:~~ <br />I~.~.r }LCw & ~; }:~ ALIC~EL C:: I•I}iC FEIi7UD5 CF LIL fC C~Eccp !,':AC I' .. '.A7 L.".LC`'I :C [r:n. [f7ECTICp LlP2i_-LEE I.t .e• <br />. -• .. + ,r r ~ w ~ s ~ . P ~ e ~ [_ f~i i r \ r _ s ~ r ~ rl , r • V ') r r . a . f r- ~ e c - ~ u c ~ n u ,- • n a = y • .' _ ~ ~ ~ .- ~ I ~ . t c r ~ ~ - <br />~PA Form 9320-1 ~(08-95) Previous editions may not be used. (REPLACES EPA FORM T-90 WHICH MAY NOT BE USED.) C C 16 e / L` C C 1 1 1 - 1 C i . PAGE : OF <br />