|
I
<br />PERMITTEE NAME/ADDRESS prelude Fat~iry Namrllacalion if Different)
<br />NAME r ~ •
<br />. r-fib.., .._../_ ._ (•n._..,1 :.1r I
<br />ADDP.ESS;: n ~p~ r- r~:: ~^ 1 v r r c•..
<br />~'{ „
<br />~,.
<br />FACILITY
<br />LOCATION ~'~
<br />>~'
<br />__
<br />NATONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM MPDESJ FORTI ApprOVed.
<br />DISCHARGE MONITORING REPORT (OMR~ OMB No. 2040-0004
<br />Iz-rs) nr- 91 •• ..~ ~.~ Approval expires OS31-98
<br />PERMIT IJUMBER DISCHARGE NUMSER
<br />MONITORING PERIOD " ^ . " ' ~' '' ~ ~ '+ ? ' r •' ^ ~' ~ ' ~~ - ,
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~7 !111 ~~ TO oo nc ;~ .•... ... -, ~r .,• -: t -( .. .. ,.
<br />(zo-zr) (zaz]) rzazs) /zsw) (ze-zal (~+) NOTE: Reed InsWClions befor leting this form.
<br /> (3 Cercl Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4G53) (54-61) (3845 (46-53) (59-61
<br />EX
<br />of
<br />TYPE
<br />(3237) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 'W'V-~~
<br /> (ez63) 64-68 6&70
<br />'"' SAMPLE :~: r.~pr t.,~•r.y .. +
<br />( `1
<br /> MEASUREMENT
<br />lil r, :1 [ n I PERMIT daaOCrR YF re44R# Ly 5 '`*t"«-'; #-irS'QI#!] 9 n c
<br />1 h^ i".'1'~- 'ln;, 1•r REQUIREMENT M Y Krb~`i~% -_ 111 K~,In it -~
<br />'. l1 :.I')r ~ ~1'~( SAMPLE :..~.. ,.~;e :•r .. ,:.h
<br />f ~1
<br />:, ^ ~~'~ P ;;': c ~ MEASUREMENT
<br />Cl"_+!i! 1 (' PERMIT fifi#4r?1k OCROeOG ... !s6fiClr{t ``•-
<br />~y- ttA
<br />^
<br />-
<br />-bP
<br />tFFL'lE:: :N~'~ ...•,•~ REQUIREMENT `;
<br />A ]T r r -./. y~rT~
<br />~ I L .. i? F. ': 6 S ~ SAMPLE . . tt
<br />/ ~1
<br /> MEASUREMENT
<br />~0`, `>f~ ? O n PERMIT 64OS~01 (~ 4Pt3 rk4x y 01&"!dt#yL4 ~' #rD'4+d ~ r- n'ITT 4~ ". neP
<br />1. r ? 1_ f7 t ; r. ~ ~ r REQUIREMENT % - - + ~- `~`
<br />'.:.) SAMPLE •. r'.•:k ..... ;: rte +•r. ~• r ~ :~
<br />m ri :". I. !::i `.: (~~ V > .'. A ". MEASUREMENT
<br />V ~I'•~:1C I f' .1 PERMIT SY L1'¢ORO 4R~401 tt
<br />~~• Or?rf Cr#!~`` ;a. Q. ~vn~v ... .r .. ]:/ q9q
<br />~r;. i..)a;„'r f;c 1'_. ']. •,.;: REQUIREMENT ]
<br />- ~ SAMPLE -_.r, ..^;: .. ... ., r , ;1
<br />. r~ 1. r^' J V r r. S~ r r MEASUREMENT
<br />V l'1'~i ': I "' PERMIT rr *f##bt'J "Grx ^sx,; ..... D"xfi~«„k .y
<br />~ ~l.~F>~
<br />~ ~ k"~/
<br />~..
<br />^ ll f"
<br />^ .. .. .- .1 i ', V t ~ .. r
<br />L REQUIREMENT i .. .. }
<br />t.L_I
<br />r TA. ,-~.~~,1_. -. .. SAMPLE (
<br />r•11 ,, ..:,,.. ~.:.:..~,. ,~
<br />... .; ., x,.
<br />.. . .
<br />~; ~ ~,1 ^ ).. ; T . x•., m ;• L r, ., MEASUREMENT
<br />`: r),7 ~>'.) I :1 " PERMIT .Q3 BEPDRT Rr:aE3fi #E1Rdd¢ k44 #RKL~;~ A F,£I(j.9 ~a }'!'Au
<br />. cc•+• :, •1r ; ~-; - ,•ft •.% REQUIREMENT ODA Ap:r ',?~
<br />-r
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E7UMINED AND
<br />IN
<br />AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL ,
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING /" ~ -
<br />Kichard L1fIIs THE INFORMATION, I BELIEV E THE SUBMITTED INFORMATON IS TRUE, f! ^ ~ '
<br />
<br />6
<br />i
<br />l ? ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING I AM AWARE THAT THERE ARE SIGNIFICANT
<br />FALSE INFORMAT
<br />INCLUDING THE
<br />N . • ~; ~~~
<br />w
<br />ronrTlenta
<br />.1anaryer IO
<br />, _ ,~
<br />70-
<br />70-~ 7 ~ 2
<br />7
<br />Z E
<br />99
<br /> POSSIBILITY OF FINE AND IMPRI SONMEM. SEE 18 U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL IXECUTIVE
<br />TYPED OR PRINTED mazimum(imnssonmenr o/behveen 6~monm~s enltl5utle litres up b 510,000 entl a
<br />pn years.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence ell attachments here)
<br />r~L.~)~• [,nw1~ yn.~. .p~. ~:.+Ty._l i'i.7~i "1•.: n~T. nn: nT~1~ .~rT _ .r. .. r. .,1, :p..r.r 4. -•o.c, ..: -+„~ TV'
<br />,~
<br />v. '•f. ;.L- far°' T' .. .'L"~. -qm pLT iA.°"(."\" rl. JL•rm T^. r~ -?. .
<br />EPA Form 33247 (08.95) Previous editions may not be used. (REPLACES EPA FORM 7-40 WHICH MAY NOT BE USED.) PAGE OF
<br />^OTnI /?~ r'•? '-1 571 1
<br />
|