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<br />PERMITTEE NAME/ADDRESS pnclude Fariliry NamdLocarion ijDi$ennq
<br />NAME ,
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<br />FACILITY `
<br />LOCATION
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<br />NATIONAL POLLUTAM DISCHARGE EUMINAIION SYSTEM (NPDES)
<br />DISCI2A6 GE MONITORING REPORT (OMR;
<br />(I]- 9)
<br />nnvuln n~~ ~
<br />r PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 9 v '+a p l TO n^ ^ r, ] r
<br />!20.211 /28271 114-251 R&2l) (29-291 (3631)
<br /> Form Approved.
<br /> OMB No. 2040-0004
<br />" ~ """ Approval expires 0531-98
<br />
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<br />NOTE: Read Inslrudions befor o(npleting this form.
<br /> (3 Cell Ony) QUANTITY OR LO (4 Certi Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-87) 38-45 (4x53) (S4-8f) EX OF TYPE
<br />(32-37) AVERAGE MAXIMUM IJITS MINIMUM AVERAGE MAXIMUM UNITS
<br />/¢~1) ~~~/3
<br />(6468)
<br />69-70
<br />F'!I SAMPLE ... ... .. *~' ,, ,. .., ., ...:+ ! ~ ~7
<br /> MEASUREMENT
<br />(I T1u (.!U I (' n _', PERMIT ~~Gara1C %r-4140:RCt .. ~;~, :kr#*flblttCi'~. 4 R NCC/ 'Pll !?
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<br />';!7LIU:>, °•`:T'.'L°q'.;.c SAMPLE '•rr::^.: r.,;~,-. ek4ln/Str ( -r.•
<br /> MEASUREMENT
<br />L ..1 ~,LL~, 1 J ~'~ PERMIT 6dGG?is G+x tY4GS' •n f ;
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<br /> MEASUREMENT
<br />U05~6 I D 0 PERMIT Ar7mRlihfEq' CR4'4aDr •.r:r G4~At#lY+-~, IOt#~- : 04*T4 7?A n
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<br />NAME/TITLE PRINCIPAL FF1rECUTNE OFFICER I CERTIFY UNDER PENALTY OF TAW THAT I HAVE PERSO NALLY EXAMINED ANO
<br />TELEPHONE
<br />DATE
<br />AM FAMILIAR Wm1 THE INFORMATION SUBMITTED HER
<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON
<br />1 9EUEVE THE SUBMITTED IN
<br />Richard Alills THE INFORMATION EIN; AND BASED ON MY
<br />SIBLE FOR OBTAINING
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<br />1
<br />j
<br />FORMATION LS TRUE
<br />,
<br />I AM AWARE THAT TH
<br />ACCURATE AND COMPLETE /
<br />,
<br />1
<br />,' ~ /~
<br />ERE ARE SIGNIFlCANr ~ ~/ ~ F" /~
<br />.
<br />Environmental hAenager PENALTIES FOR SUBMITTING FALSE INFORMATI ;~
<br />ON, INCLUDING THE 970-87O-27t2 T 2E 99
<br />POSSIBILRY OF FINE AND IMPRISONMENT. SEE 18 U.S. C. 4 1001 AND 33 U.S.C. SIGNATURE OP PRINCIPAL IXECUTIVE
<br /> 4 1318. (Peroties antler 0rete smrures mey Inclutle lures up m 310,000 erM a OFFICER OR Al1TMORIZED AGENT NUMBER YEAR MO DAY
<br />TYPED OR PRINTED menmum Impnsmmenr of Eetwsen 8 mw0u entl5 yeen.)
<br />COMMENTS AND EXPLANA NON OF ANY VIOLAiIUNJ (Helerence an aRacnmenrS nere)
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<br />EPA F"orm 3320-1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NO7 BE USED.) PAGE OF
<br />^0:}~R/9~ ~rL12-1 523 1
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