|
PERMITTEE NAME/ADDRESS (Include FaciGrv Name/Lrxarion JDi$erenq
<br />NAME Tka VPEF ;f ^.T" r•~~-
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES)
<br />DISCHARGE MONITORING REPORT (OMq)
<br />Form Approved.
<br />OMB No, 2040-0004
<br />ADDRESSTdA PPEt+ r .:. ~ (Jlt{;:I N4)
<br />P + ~ , BG t ; / PERMIT NUMBER DISCHARGE NUMBER v _ . j y A L ~ 0 F
<br />"HAIL ;;J eiE1S
<br />FACILITY MONITORING PERIOD ACUT:' .IE:' TESTING POH O:i9A
<br />LOCATION YEAR MO DAY YEAR MO DAY
<br />FROM i C1 1 TO O1 'Jj 31 ?'~` ";3 DISCHAP.GE'-~`•~'
<br />e
<br />4 ': ,• v : N . (i0 N 7:%'• ~ ~ 7 S _ .~ , ~{ E c. / .. E G -
<br />' completing this form.
<br />NOTE: Read Instructions befor
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION ~ NO. FaEOUENC SAMPLE
<br />fdARAMETER EX OF TYPE
<br /> AVERAGE "MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS A>yALtisls
<br />'.:~U 3TATRE Ud"k nC SAMPLE '`'4`~xA: CCC4rr0 #~kCrk~F+k 'sriv~r.^: ( .n.3)
<br />- '::? I O D (~ P8 N I A MEASUREMENT
<br />
<br />i .'!jH ,1 ': U U
<br />F""""
<br />r1~
<br />,
<br />rr~
<br />,
<br />~
<br />~
<br />*
<br />Ci;tr.
<br />ix "` ~c
<br />'
<br />yA'
<br />~;.~i
<br />ER-
<br />r'LURN'~' ~tiaR055 YILU .
<br />;i'
<br />I``:. ,
<br />,
<br />,
<br />,
<br />s
<br />a=ya F~.":., AX•r5 ~ Y
<br />IS
<br />,.,~fl-r,,,; ~ i ~ t"'~zk"~ T
<br />- :'1 ST~T.9E 9bH,. AC SAMPLE crape/4 oa~a~n i~if~t#atr a~a~aa~s~ ~ $3j.
<br />f"
<br />i:1BPNRL~S MEASUREMENT -
<br /> - ~ ~
<br />PLU3MT 'GROS# VALU ~N, ^'"- ~' '`; ~ ,~ t,aa _ .. ~ y.
<br />=. t
<br /> SAMPLE
<br /> MEASUREMENT /
<br /> y>~ 't-
<br />•{ r ~,~ .'-I pl
<br />ta
<br />a, . r
<br />^ ~'
<br />':, . r5 .R
<br />, (r'
<br />=%ft
<br />~ 'r
<br />~~,v
<br /> IREFA$NT j~
<br />.a fr T *~
<br />, ~
<br />4., . , i ;s',,z. f"Ts
<br /> SAMPLE A
<br /> MEASUREMENT { '•~
<br /> °°-PERMIT- -~i t`~.,r,-
<br />
<br />~ ~.:;. W~
<br />L
<br />!
<br />,,
<br />r t, ~ .~
<br />
<br />i r-;W •a a
<br />
<br />~
<br /> REQUIREMEN'~~ ~
<br />~ ~~ / y
<br />k r°~~ 'T ,
<br /> ~ .
<br /> SAMPLE ~ 1
<br />" MEASUREMENT '
<br />- -PEHMIT~;~= = ~ ' ~I~ ~~.r;, .'~° "~"•;~ `'I ,'. '<,~s w,<J t t~" ,
<br />
<br />
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERM171 rt, '~ ~~+ *~rk
<br />. ~ w ,~ ~ ,.r: k ~ fir- t..
<br /> RE©UIREMtnNI ,
<br />~ t s r lr.. ? ` ~~ $ •y
<br />'a•.
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ?P Mlfi= .'` r
<br />
<br />t = ,~ a
<br />
<br />' '
<br />~`3
<br />~
<br />Y 1p
<br />tr
<br />~
<br />'M'
<br />`
<br />II 1y ~'
<br />N`
<br />'"
<br />+~..
<br />r
<br />
<br />~
<br /> flEQUTAEM~NT :
<br />k k . ,« ,W-
<br />~
<br />~ _ ?S
<br />M
<br />~ if r
<br />.
<br />f
<br /> 5 _ i
<br />. k. e
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Ceniy under penalty of Law that this document antl all attachmenLS ware
<br />i
<br />i
<br />i
<br />l
<br />I
<br />d
<br />i
<br />tl
<br />i
<br />tl TELEPHONE DATE
<br /> prepared untler my tl
<br />rect
<br />on or suparv
<br />s
<br />on
<br />n accor
<br />ance w
<br />N a system
<br />es
<br />gne _
<br /> toazsure lhatW~fied persomeLproparly ga0w endevaluale the inbrmatlon
<br />ubmitted
<br />Based onm
<br />ln
<br />uiryolthepermonor
<br />ersonswhomana
<br />elhasystem / //
<br />~
<br />( C
<br />/~ L'"-
<br />4
<br />40
<br />W. Gordon Peters .
<br />q
<br />p
<br />,
<br />y
<br />g
<br />s
<br />or those persons diradly responsible for gathering the inlormalion
<br />Ne inbrmation ..-
<br />~- -4
<br />1
<br />970-82 OL 04 26
<br />President /GetLetal Manager ,
<br />submmod ls,to the best of my knowledge end belief,tne, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED I em aware That there are signEiwnt penalties for submtting lake inbrmation,
<br />includin the ossidli of free antl im isonment for knowin violations. OFFICER OR AUTHORIZED AGENT A
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION Of- ANY VIUTA 1 IUNJ (Harerence all artacnmenrS nere)
<br />,: I.A.1, PP 1-4, FOR D~TAI LS OP T°iT PR]C EDU3 E+ RF'.P'.)HT LCSC - STATISTICAL PRINT ESTItlA?E YHICH ii
<br />_.'fiAL TO BUY OF TEST JR04NISN5, ANC ATTACH ACUTE TOXICITY TEST RPPORT FORM TO DI'IH. COPIES OF ALL
<br />EPA Form 3320.1 (REV 3/99 Previous a pions may be use ~ ~ ~~ ~ ~ 3 $• 0 GE ~_ O
<br />Jr1I17ao innn~s+
<br />A 'f
<br />i,
<br />
|