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PERMITTEE NAME/ADDRESS pwe64 Frmry N.w!<ranon dDyGsp <br />NAME :I :.~~. _J:iL L''.)~rf~., I' <br />ADDRESS G n n R :: Y I~~ <br />dAYU~N <br />Cu tii~3") <br />FACILITY <br />LOCATION li .4 Y ~~ c :. C~ 1 J L^ 3 ~ <br />r.T;;:: v. :IUli i~::l"d '.E C, f.!; t:~AL .."n:.AC. -. 'ri <br />NATIONAL POILUTMT DIBCHMOE ELIMINATION SYSTEM INPDESI <br />DISCHARGE MONITORING REPORT (OMR1 <br />l1-161 17- 191 <br />+'i:•0700i2i CCO A <br />PERMIT NUMBER DISCHMGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM r1 ~ U TO "" l <br />(16211 /22-131 ULJ51 /24271 /78-291 !30.311 <br />Form ADProved. <br />."~ ": F A i • i 1~ •~. T .,gMBiNo„204(~-000p <br />li F c F ~ pprovel axpirles~05.31-98 <br />(~ ) I.:s r <br />- F?PAL <br />`?°CH <br />NOTE: Raed Inetructiaw belaa completing this form. <br />PARAMETER !3 6Ta Onlvl QUANTITY OR LOADING .R and only! QUANTITY OR CONCENTRATION NQ FREQUENCY SAMPLE <br />l31-371 I4G531 /51-61 /3BJ61 !46531 15461 of <br /> EX Mursls TYPE <br /> AVERAGE MAXIMUM UNIT ~ MINIMUM AVERAGE MAXIMUM UNITS !st-s31 16468/ /58-IDl <br />AS 1 ..r :A~~` SAMPLE .:; nC=r,::;: ( '7;1) ari :Gri4 a..r.:-: <br />Y I .:+v A L MEASUREMENT <br /> <br />B'/dr.: i 0 ~. <br />' PERMIT '=>;,#:YK: <br />iiI:PDR1' c- <br />E.--1 <br />4fiSri+6i11 w <br />fdr,.,{.;. <br />;Yrlf;.1_y <br />;LY <br />;.:,I?.: <br />:.FF:,Ut;:T ,;E05~ l'AL"! REQUIREMENT Ia~P kAX NC~Q <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQVIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENUTY OF LAW THAT I HAVE PERSONALLY E%AMINED MD <br />AM FAMILIM WITH THE INFORMATION SUBMITTED HEREI <br />D B <br />ED ~ / TELEPHONE DATE <br /> N: M <br />AS <br />ON <br />MY INQUIRY OF THOSE INDINOUN.B IMMEDIATELY RESPONSIBLE FOR <br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IG ~ I ~ <br /> TRUE. ACCUMTE MD COM0.ETE. I AM AWME THAT THERE ME <br /> SIGNIFICANT PENALTIES FOR BUBMITTING FALSE INFORMATION <br />INCLWING <br /> , <br />THE POSSIBILITY OF RNE MD IMPRISONMFNT. BEE IB U.B.C. E 1001 MD 30 SIGNATURE <br />F <br /> <br />U.B.C. E tGle. IPrrMF. uKFr dww mnma mry YcAW Fiwa ~ ro J10,000 O <br />PRINCIP L EXECUTIVE <br />AREA <br />TYPED OR PRINTED .rvdnrairx.n bwicwnntw Mer«n smonm..nesv.r.l OFFICER OR AUTH REO AGENT CODE NUMBER YEAR MO DAV <br />G VMMCrv I J ARID CAYL.An1A I I V H V h ANT V I V LA I I V NS lHBJerenOe I// effeC/Imen /S helBl <br />.-,~: L1:._i +ILL ., ep:bcJ A.FS 5 'I :1..^.Ar.L~. -:.L1'>> -.IF'2'I ;l<..,T CC F~ C=?fyFF~~I•,~~ 1~ Ir- •~"- ~T• ... . <br />-_LILiS•,i_ _"iL'J~ ..I"iT r.nIYED•F:JF. ~iJYi?F24.i5 ~!1;:Ci!` -'r:. 'U~JTC'! iC El.'fi CT rFO~)F i\ I.A.I. O" , <br />EPA Fam 3320x1 108-95) Previous edmone maybe used. (REPLACES EPA FORM T-0O WHICH MAV NOT BE USED.) r. U 0 3 F ~ f 7 ] C; , I - ], 5 i ~ PAGE ~ OF <br />