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<br />PEKIMITTEE NAME/ADDRESS (include Facility NamdLacanon ifDifferenq
<br />NAME fkAf'?E9 ~'•:
<br />ADDRESS ~ n ' ~ e j
<br />1411, Pi:R
<br />P.O. 'f'.
<br />FACILITY ` ;~ A i L .~ .I I~ J L `. ~,
<br />LOCATION
<br />nil. t: .~ (;J iJ(lr (':^~. :.i. :./-i.9
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPOES)
<br />DISCHARGE MONITORING REPORT (OMR)
<br />PERMIT NUMBER DISCHAAGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM J 1 ) L l i TO J 1 0 3
<br />Form Approved.
<br />OMB No. 2040-0004
<br />* I :~ 7 !~
<br />'IT'.-'r3 -,G:' TO CgYOT:. GULCtf
<br />:"~: `:: ~ L. ~i it AiivE II {{ ~~ ',~+'at
<br />NOTE: Read Instructions befote~ttlpleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX OF TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ,wuYSrs
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<br /> MEASUREMENT
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<br />:NAMERITLEPRINCIPAL E%ECUTIVE OFFICER ICenity untler penazry of law tnaz this document and all attachments were
<br />d
<br />i
<br />i
<br />i
<br />i
<br />d TELEPHONE DATE
<br />. on or superv
<br />preparetl un
<br />er my tliract
<br />on
<br />n accor
<br />ance with a system designed
<br />s
<br />to assure that quaufred personnel properly gather and valuate Ura inbrtnation
<br />r~ /~ ~
<br />f.G- `
<br />W. GoYdon Peters submitted. Based onmyinquiryofthepersonorpersonswhomenagethosystem, ~
<br />~f" G ]O-$2~1-/i~iOl OL 04 ;'h
<br /> or Rwse parsom Erectly responsible br gdNOnng the inlonnation
<br />the iMOnnazion
<br />President /Ge:te r:.l Panager ,
<br />submitted is,to the best of my knowletlge end 6eiiel,tme, accurate, antl crompleta. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED I am aware Ihat there ere signiBCant penalties br submeting false inlorma0on,
<br />indudin the ossibih of fne and im risonment for knowi violations. OFFICER OR AUTHORIZED AGENT A -
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all anachmenfs here)
<br />!J3 E TOTAL It:U.u LI".li ~ ,!;.:. ;A:1..C, 0.y(> SBTTL`cA`1~L _;Oi.iDS LI?3I'f APPLIED FOii <=10TR,Z4HP FRECIP SV~,!,T-
<br />J:: i•: ;i lJ»UF;N )F P30:;F ,'~I. .. ,.. Iv: ^: '- [•a•3. PF:RMITT(i ii °, IJST TAKE 0.LL RE950NA5Lk l18A 4UR. F.S SO REUUC F. P
<br />PA ol`m`~33 -1 R~V3/9 `Previous editions may be use - ~ ' ' '- ~ u' ~ ~ ~ ' ~~ ~ ~ R e ~~_^„ TH .I _ ~• OR G
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