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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 />