PERMITTEE_ NAME/ADDRESS(Include Facihry NamdGxanon i/OBrrenq
<br />NAME ~ n ~ ;r r r
<br />ADDRESSg A c L ;. ~ r r~ -~ !y n{ v y
<br />P.O, ,.~Y
<br />rrTr;, ^O R1F,75
<br />FACILITY
<br />LOCATION
<br />
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) Form Approved.
<br />DISCHARGE MONITORING REPORT (OMR; OMB NO. 2040-0004
<br />Approval expires OS-31-88
<br />PERMIT NUMBER DISCHARGE NUMBER ~. _ ~ ~ „ ~ , „ ~ ; s
<br />MONITORING PERIOD '' ` ~• '~ - - ° ~ ~'+ r ` '') ` r T T y r ^ e~'-' r v
<br />YEAR MO DAY YEAR MO DAY _
<br />FROM 9 ^~ 9 ~ TO ~ ~ ~ f T. ^: ~, ., ., a .- ,.- .... ,- . ( ..: ~-
<br />fzo- Izz-z3) (z4.z5) fze-v) pa-291 f7aa0 A NOTE: Read Instructions b ret leting this form.
<br /> (3 Card Ony) QUANTITY OR LOADI (4 Certl Ony) QUANTITY OR CONCENTRATION NO. fREOUENC SAMPLE
<br />PARAMETER (46-53) (54-61 (38-05) (4fi-53 (54-61) E)C Of TYPE
<br />(32-37) AVERAGE MAXIMUM U S MINIMUM AVERAGE MAXIMUM UNITS
<br />fazm! avers/5
<br />(fi4-sa)
<br />6370
<br />i' :i SAMPLE .. r.^ h :r h ,: ,. ...?+... / -,~
<br /> MEASUREMENT
<br />f~UUUD 1 :) PERMIT 9rO4bArC ~C4grptl! ~~,F~4 pF.6lhtrikhdr w^ r' Hr-v/ 'Rqj{
<br />FFFLUh'( ,N"!-" 7~f 1• REQUIREMENT .- !} K pr+v - n ra
<br />~4L?US, .,'.T°.i.'.~ SAMPLE ... .. 5n ;, .. R..e,s~h f ,..~
<br /> MEASUREMENT
<br />r'U~•~; `; 1 (.' n PERMIT TeX r3>fG0 fr P~F4R4' .,
<br />,-- ktOAb~t 2.. SPAR! w5 4.^-F/
<br />. n;p
<br />.
<br />.FY L'1E'i T- ;;F'+` Yei.q+ REOUIREMEtJT r ,~ t•• T v w ~ J' :T ~. TU
<br />~,IL !;:;"A' SAMPLE .: r•rr,y 4^. ^;?^C~. - .. ..+.... re ... ~.... r ~~
<br /> MEASUREMENT
<br />l;•U;LI~ 1 L` D -'.PERMR Lfl14#dp etR49LpC -##4+R#>.: 4? 3. Q. ON'('?",', aAt.
<br />}•~r~Uc.KT ~~u1~~ ,1~}na ACQUIREMENT _
<br />
<br />~ _
<br />~ w
<br />e.
<br />rp-
<br />FL')., I'f Cf)~; t•fI7' ~~ SAMPLE ( '
<br />; TI ..... e'+deY r.da •c +:-°
<br />T rl i ^ T ~ '-: A'T "' "~ '1 ^ ~ ~ I :. •; + MEASUREMENT
<br />0')', () I '! ~ PERMIT. AR F13g2 Rf P;1RT hedf!e ex tlr .. ... 44'#~ ~: d4#+4F r. , :. .r .. '-~C/ ~y~T'A •;
<br />f,rs•r •f•pr rL •~ t ,~ REQUIREMENT 3fl Ps A~ w ^^ I ~v
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT .•_~ - a:
<br /> REQUIREMENT ,,,yt , -
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT ~
<br />~ ~~` ~ ~ '
<br />~ -
<br />t~" -
<br /> REQUIREMENT
<br />;t '
<br />_
<br />c ! '"i ~~
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT f+"f,:
<br /> .REQUIREMENT - - -- "°'•`'~'
<br />~
<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />A
<br />T
<br />E
<br />RM
<br />I
<br />N
<br />UBM
<br />TED
<br />ERE
<br />AND BA
<br />ON MY TELEPHONE DATE
<br /> H TH
<br />IN:
<br />AM FAMILI
<br />R WI
<br />INFO
<br />AT
<br />O
<br />S
<br />IT
<br />H
<br />SED
<br />
<br />Richard Mills INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />THE INFORMATION, I BELIEVE THE SUBMRTED INFORMATION IS TRUE,
<br />T
<br />T
<br />E
<br />S
<br />NIFI
<br />NT / ~ j
<br />i A ~J
<br />'
<br />)
<br />'
<br />//
<br />M HAT
<br />HER
<br />ARE
<br />IG
<br />CA
<br />ACCURATE AND COMPLETE. I AM AWARE
<br />WCLUOING THE
<br />R
<br />UB
<br />IN
<br />FA
<br />FORMATION ,
<br />(
<br />/I~iYi .- /~ 970
<br />870-2712 7 28 9
<br />Environmental
<br />anager PENPLTIES FO
<br />MITT
<br />LSE IN
<br />,
<br />S
<br />G _ t -
<br /> POSSIBILfrY OF FINE AND IMPRISONMENT. SEE 18 U.B.C. 4 1001 AND 33 U S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />TYPED OR PRINTED 4me1xi lmu'rli~P~n /mmere ur rn am~on~~S~~Ti.as upmEf0,000 eMa OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />GUMMhN I S ANU tXYLANA I IUN Ur ANT VIULA I IUNA' (IYe18/eRCB a/I aRaCRmenlS neIBJ
<br />,~T°-Lt;.AaLP, "7LL^"> ?.T"T~ 113iYr'i~ F7}i ~lr~y;.e~gy~ pccf-Tn Ch: -f r.n_r~~~7~ o.^. Tv~r-), r~,rirprMr4TS~ nTT, ~.
<br />GwF.ASE G4.A !' ~A°..r .. !<!: Ai_F 725 HF^i1T cr1 Tc 77rTPLF S",^.r e; 7`• r~ne;ppq EDw 7o*~{v ~,.-.. •.•r T•'°Tn~C+TnV°.-;.", ~~,
<br />EPA dorm 3320-1 (OBAS) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br />007?! /q~n•IT Z-152T ?
<br />
|