|
PERMIT'EEE NAME/ADDRESS B"d.+. FSWry NaWL«MIm UOIeG.a.O
<br />NAME . ~ - ~ ~ /•
<br />'~. S , ., ~Y '..~ l'..,1. -
<br />ADDRESS { .' - i
<br />. ~.. ~ ~
<br />. L ~ c
<br />1. .J ~~1 ~!
<br />FACILITY
<br />LOGTION
<br />.}T' 'i: 7:y (I L, T: t;Tir VV pf L~; -:~
<br />NATIONAL POILUTMT DISCHMOE ELMINATON SYSTEM INPDESI Form Approved.
<br />DISCHARGE MONITORING REPORT IOMR) .:. ~ • OMB No. 2040-0004
<br />7461 /l7-191 - "
<br />~ I L, 1 ~ ~.~ ..? I , } (, ; .. , .; ; APProvel ezpiree OS-31-98
<br />PERMIT NUMBER OISCHMGE`NUMBEA . '' J
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~ n _' I v I TO r .y . ~ I ~ ... :. ~ .. - . ~ f :.. .: ~ _ _ ~ . + .
<br />!2621/ l12-231 !2426/ I28-271 28-291 13631/ NOTE: Raed ImtrucUane before completlnp tha form.
<br />PARAMETER !3 Ard Ontyl QUANTITY OR LOADING !4 Grd On/Yl QUANTITY OR CONCENTRATION NO. ~E°U~n' SAMPLE
<br /> N6-53 f5a61 138-451 146-531 154611 of
<br />!31.371 EX
<br />MALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !4]-e]I /54681 169-701
<br />.~, SAMPLE a x .Aar • s a x w o + .. w F~
<br /> MEASUREMENT
<br />:;~... 1 .~ :PERMIT ~.. ;. ~Ake.p a.a
<br />~~ :~~k ~.r iar>''A k ». ~' ~
<br />~ ~ ~. wr+-w*« ~ :. i~',i/~
<br />
<br />~~. I r:T .:,,:.~ vo,:l. REQUIREMENT
<br />.. :.... ~ ~ ~~
<br />. ~..~.:~ ~
<br />~
<br />
<br />a a
<br />,niiN.F.,,iL,.
<br />..
<br />
<br />', t,
<br />_
<br />` ~ "~
<br />;.( _ , r T,~TtiI SAMPLE kakxex +rxxAk xr.aA~. ~ 1 ~1
<br />' MEASUREMENT
<br />.,.~.
<br />:
<br />I
<br />~ ~:: :PERMIT ~:: "Awa'3.w.~ :..Gt sa.ws, : -»a si w+a,. 'I~' ~ ~ i<(. ~./ ...
<br />..
<br />I~I:! :11~~ V~'li,
<br />~' REQUIREMENT
<br />~ ~ ~ aix ~~ ~ i/[. ~~1S Vt. .k. 4. .•j. 'I~.i/L 'i
<br />iL ... _ SAMPLE »Ae.: a,. wmA xax M1tiRRR >.e-.i. { 1~~7
<br /> MEASUREMENT
<br />:_ 7 _, ~. ~.:.PERMIT ~. •'e#A~i~rt:.~~: ::~xx.r;:»x fi .x,: ..ke~r~n ~r ..l:.so i.3' '.':. ....
<br />c-~.; ,., ~. •"ti:. Y11Ltl- .REQUIREMENT: ~.::. ~~. :~:-..' ~ trA ~~. ~ 1:.: •: ~: i~ ::/L
<br />r.
<br />-. .
<br />., , _ _ i : >: ;111: i ') :' SAMPLE ( , ;.) • k n x t o A . x x _ v e a x r ., +
<br /> MEASUREMENT
<br />I.'L,, }:;•.I~
<br />~N'1 i
<br />-
<br />
<br />. ' _. , i
<br />1 _ '
<br />.. ...~ ~.: PERMIT.. '' ~ ~r.::.::
<br />~. '' ., in f ~. r.
<br />~ .: p„~Pv;;~T
<br />
<br />~: ~~>•>t~. ~.... per a:.e ,.. x.,,. ... ,L:
<br />
<br />=^: REQUIREMENT ~:. ~
<br />..
<br />~
<br />t
<br />~: ~:
<br />l
<br />i .
<br />L. X': :•: r:
<br />~F
<br />:, i
<br />'L i
<br />~ .
<br />..
<br />s ~ .. dT
<br />JaL:i! ..
<br />.u ,
<br />:.
<br />is
<br />•
<br />t ,
<br />~
<br />•,U~ ~ /, r.,L SAMPLE i+wwr.• aAtretik xew+at ( Ir?
<br />~ MEASUREMENT
<br />~
<br />'I.4 __
<br />
<br />. ~ I 'PERMIT.: '
<br />.. ... .:.A »''A R'»A.. »R rt'vde w
<br />.. +a. +rrAn-.axe-
<br />~ =•1 jt.td'<i. '.
<br />, P:,<.. ..
<br />,
<br />'
<br />d
<br />'
<br />• .REQUIREMENT. . ~:~.: :~
<br />.~:
<br />' :k.x ~ ~ .>T,. ~~„~:~ ~~ii
<br />~T !I
<br />; ;
<br />:=: .i,
<br />.: 1
<br />:,; •. '.
<br />J ..
<br />::. . .... .
<br />,L -.., .: i.~ SAMPLE »aeA+« ,~) rx.xiA x..aa .+ ..~,,.
<br />;L
<br />MEASUREMENT
<br />i ~ PERMIT wirii# 6'~i=6<T y' cc} akeAR• xx k.~ e«n+.+• w ,. r. i, L...
<br />r,- 'i1 ., '; _L,I . :FEQUIREMENT ~.4.T. i3:•,iC. •i'='~ .. ..
<br /> SAMPLE
<br /> MEASUREMENT
<br /> .PERMIT.~~:~ .:
<br /> .HEQUIREMENT~ .~::~~~:~ ....:..::::::.:.::
<br />NAME/TITIE PRINCIPAL EXECUTNE OFFICER I cERn
<br />AM FA FY urlDrn PENALTY of
<br />MILIM WITH 7HE INFOR uw rxkr I NAVE PERSONAUr E%AMINEO MD
<br />MATION SUBMITTED HERDN; MO eASEO ON TELEPHONE DATE
<br />(~l / ~ ~p
<br />'
<br />S MT INOVIIIY OF TH09E INOIVIDUAl9 IMMEDIATELY RESPONSIBLE FOR ~ !
<br />~
<br />I
<br />~
<br />\ ! `/
<br />/:6 ,1 ! / / `! ~ / / ~ OBTAINING 7HE INFORMATION, I BELIEVE THE 9UBMITTED INFORMATON I9
<br />TRUE. ACOUMTE MD COMRETE. I AM AWME THAT THEME ME ~ // ! ~ / , 7 ~
<br />~
<br />__
<br />I,
<br />1
<br />i ~
<br />„ (
<br />~~ S L! _
<br />
<br />SIGNIFICANT PFNALTIE9 FOR 9UBMITTING FALSE INFORMATION
<br />INCLUDING ,
<br />~
<br />~
<br />~
<br />~
<br />' • `
<br /> ,
<br />THE POSSIBILITY OF R
<br />E MD
<br />NMENT
<br />EE 18 U
<br />01
<br />MPN
<br />S '-/ ~) ' ~
<br />/
<br />~ ~
<br />~
<br />/
<br />'~' r' /' ~"'C
<br />'
<br />' M
<br />I
<br />90
<br />. 9
<br />.
<br />.C. 1 10
<br />MD 37 BIONATURE OF PRINCIPAL EXECUTNE .~ , ~
<br />T -~ '/ ~
<br />~ U.9.C. f 1Jte. lAwltlaF utl/ drw aErema,>~Y L+rAW A.r.W ro JIO.IXlO AREA
<br />TYPED Op PRINTED .ndYTp[wlx.R weMo++wnraatw«namonmsweY..RJ OFFICER OR AUTHORIZED AGENT CODE HUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANA (ION OF ANY VIOLA I (DNS /RI/BIenCI a//ettec/Iments /)elel
<br />EPA Farm 3320-F 108.96) Previous editions mey be used. (REPLACES EPA FORM Td0 WHICN MAY NOT BE USED.) , , / _, T .1 T _, .I ~ PAGE ~ OF
<br />
|