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PERMITTEE NAME/ADDRESS RrE,e.srdlryNrw/Lo[.Ilq 1/DIObrO
<br />NAME r~Ae':'i ; YLXI ..~~, I'.~.
<br />ADDRESS L [t A P 1' I ~~ i.
<br />P.J, P~~J1. ] `~7
<br />i::c .;. ~ r, .. lr.
<br />FACILITY
<br />LOCATION
<br />NATONAL POLLUTANT DISCHAflOE DJMINATION SYSTEM INPDESI
<br />D16CHARGE MONITORING REPORT IDMR1
<br />Z-15/ 17.19/
<br />000 0 3 2 11 5 COT !'
<br />PERMIT NUMBER DISCHARGE NIN.IBER
<br />MONRORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM TO :. J
<br />116111 !1Z-?3/ II~F-15/ 1I6P71 /28-19/ !36311
<br />Form Approved.
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<br />Approve eXp r SOS-31-98
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<br />NOTE: Reed MetructioRe before completlnp this form.
<br />PARAMETER /3 Grd Only! QUANTITY OR LOADING /I Grd Only) QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
<br /> 115-531 151511 138-5/ !4653 15L51/ of
<br />131-37/ EX U'I'uYN4 TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rsz-e]1 '
<br />(5F581 (59-701
<br />F'~ SAMPLE 's#~`;: r,:f ~;: ek#^.~ {: ^r ''6 ..'.1
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<br /> MEASUREMENT ~• ~/ d v ~ .vFA7A'
<br />JONJO 1 G G ~ ~ PERMIT
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<br />~J 1 5, a L •A. Lr, SAMPLE ~#C39. L::}b0#4 9aa9aa ( 2S)
<br /> MEASUREMENT 4F ~~ / ~ a, /
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<br />.: a, i I SAMPLE ....;-6;: ~~--'k0{: :k 9aA99r, =.C 1096;} ( lq)
<br /> MEASUREMENT ~~ ~yq N,q
<br />i3Ss)~ 1 ')0 J .PERMIT ': '.S<3'~rs.. ~##~f%k~ - ::Jt: Cr.~Yvt:O 9^t?Ot,.~ ~( ON?1 4r~F
<br />~t'FLUGAiT CRO$5 YALE! .REQUIREMENT Cr,;:
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<br />~ SAMPLE ( G3) ?1 :999t 9x 9'v •, ,~ Ct,. •.',;
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<br />t~~NT PL~!~" MEASUREMENT QU 3 ~i,1S (~ ~ ~~S/9~
<br />'.UJ~U 1 Q' ;` PERMIT kh:FQ~3` . .: !!~POItT r9t:p9~ 3a'.C~# b9#4w{,. :{:+:_•. x; :.}:LY T:i3'"Il!
<br />.FYLJLhI G OSS VALU REQUIREMENT :JOtf A:;.1L~'&:;: ;%: ALLY .!S X. hlD ,fir{:
<br />~~ - F T ~ L SAMPLE 0rIR 01040 C::}rt O:k :;: :7r09y'.- ( 1 ~)
<br />~L'i~OLYCU MEASUREMENT ~~~ ~ ~ ~/
<br />101'15 1 0 0 PERMIT ~ ;? 4'E!x# Y~J;: _n9a~>ar~t ~cf2lcMh~L ~~..R1~;Fna~' ~ "2!tt.Y ;4AN
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<br />V ~ h ~s A.,~ SAMPLE .. -~^'!' ~ ( 9 ) 59999 t, 9000-y; 99aY1++.`•
<br />Y 1~ ll A L MEASUREMENT
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<br />J4Utici 1 C' - PERMIT •-. %fu A PDT E`_'=1 ;~=,r,4~a xx4n n ~~lE~a:t#. :*..;:-: w;;h:LY YI;UA!
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<br /> SAMPLE
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<br /> AEQISIRE.hAENT ~ ~ ~ ~ .
<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT 1 HAVE PERSONALLY EXAMINED AND
<br />AM FAMILIM WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON TELEPHONE DATE
<br /> MY INDUIRV OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE fOR
<br />
<br />W. LiOLaOR Patera OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUf. ACCUMTE AND COMPLETE. I'AM AWARE THAT 7NERE ARE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING /J ~ t -
<br />G may"
<br />70-824-4401
<br />8
<br />4
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<br />iNE POSSIBILITY OF RNE AND IMPNSONMENi. SEE 14 U.S.C. f 1001 AND ]] t10NA7lME OF Mi1NCIFAI EXECUTNE
<br /> U.S.C. E 1 ]Ie. (MIwTb. M1Mr drr NRR~. R1eY MKAreA fiw. Ip n+ S fO,00D
<br />TYPED OR PRINTED w.r.wxu.r.n ero.:rwnrn orNlwrnrmenNa rM eYrrAl OFFICER OR AUTHORRED AOENF CODE HUMBER YEAR MO DAY
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<br />~:,i•iLrn:1L~. ~JLInS LI"fll' Y.dY [tE 4'ALV~!i FOR >l0YR,24Hii PR~1~IF fYF:TT - OFF AIT~PRA1t' LIMI°ATICfS U![UEH
<br />;.A.1.D, Ah'D ALSO 9llAD!:h Oi' PPOOF' 3EtilUZRGMSYT; UNpCfi I.A.3. CII E GFB!ISF, - °FP 7. ?. 1.(v). TUS
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<br />maY ba uaed. {REPIY.CES EPA FORM T-AO WN1CH MAY NOT BE USED.1 TUG 3 2 / 5 ~ ] 211-16 4 (: P'4GE lOF ,
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