|
PERMITTEE NAMEIADDRE558wdvlr FrlOryXaWLoranm VDlCe.v)
<br />NAME .,Lf'31Td1.{ to : AV ;,! _ ~, C'15T. ;, (;.
<br />ADDRESS T :., F L i
<br />p~u~ ~il) TS:.
<br />'.,J~'' ~ Ci' cT )~
<br />FACILffV
<br />LOCATION
<br />.1"T J- ~I~ti1R;l i_ TT7~ii TSr VP JF CUIdS
<br />NATIONAL POIIUTANT DISCHARGE 0.1MINATION SYSTEM (NPDE3I
<br />DISCHARGE MONITORING REPORT (OMR)
<br />(~-fal 17-191
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM t-!' :.'4 '~' TO U'1 -. ~~
<br />!16111 /72-731 I2I-151 !7617/ /78-191 13631)
<br />Form Approved.
<br />i ~ ~ . , , -. { ,) -, ~) L ' / - i OMB No: 2040-0004
<br />( :, 'J .. ~ J ~ ~ ! APProvel ezpi~ee 05-31-98
<br />r' - ~ ~ . I~. i-
<br />1~,r
<br />... ...;,i ~::~1.1 Cafe ~__t R.:
<br />NOTE: Raed Inetruetlom bslon completing thb form.
<br />PARAMETER l3 Grd Onryl QUANTITY OR LOADWG (O Grd Onryl QUANTITY OR CONCENTRATION NO, mEOUENCY SAMPLE
<br /> 146531 /54511 l3B-051 !4653 /54811 OF
<br />/37-371 EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS /aias~ /54-591 /59-701
<br />.y SAMPLE }++A#r +##k+w RR+..R, D
<br />~~ r i:)
<br />`
<br /><- "'
<br />r
<br />°
<br /> MEASUREMENT Q a 1 JO A
<br />.rl j
<br /> Y
<br />1J+`1:~ (1
<br />,. :PERMIT':::.. )..wfr}Je.#k. 4:#.*.;i+.>ti'+ k ## T:j: q}..wk.w.. , NL': .L+~-
<br />cp .. T ,. B;1S ~, 'JAI :11_ REQUIREMENT' ~:':'.': .:~f'':.::: ~~ pi ly `1. ~
<br />~ i':,: X:, ?i ij:•;:: ili Ri_,:JT/?
<br />.~L;'Ijr TGT/;L SAMPLE
<br />MEASUREMENT ###### +#+A## }++##r -y
<br />/
<br />~ ~/
<br />J`
<br />`-j ( 1'~) ~ .-...,
<br />~
<br /> . - J _
<br />~`•- ` 1 it C1 ::~: PERMIT.:.. ..~w,i~w}
<br />w r~~.~.: .~.wi##w.;R .# ## ~:}#+~#,r;#. T:~..:. :~ ., '~ ( NL.: ^,', :.
<br />-
<br />.
<br />.p~`.1:71T ..:?0 i5. Vatll ::
<br />REQUIREt41ENT. .
<br />.:.. :. :..' :'.~.
<br />.~~
<br />+R#
<br />~
<br />~ j')DQ A~v
<br />'.a. X, .7:.v'.u~v
<br />ate/L
<br />W:2: id?/!
<br />.
<br />l'L `II.~ ',r':^1i= SAMPLE
<br />MEASUREMENT ###w RA +++##} #rw#fw ARM+++ D ~il ~ ,~
<br />S
<br /> 1 7~~<
<br />~5 ~! 1 J ~~ '-:.PERMIT::::
<br />, t#Rk+~ .::. ':.k#i4tk+ # +R #+ni+.R~AI #+R'+r# •~'.ral.: .'
<br />
<br />. ,.~~
<br />i-F II~NT i:n'Ti~S V4LU~ :[tEQUIREMENT~ ~~~~....~:.'.'r:'::':"' :'~r:.'.`'? wR# 'A':1+T.::i`t:'CF.:' 'w/L .. t$;;iJT`
<br />-LU dr Lil 10411rJLT Ui SAMPLE
<br />MEASUREMENT l,/,(
<br />-
<br />Q j
<br />O.S~
<br />' ;)5) rr#w## rR Aw., RRR wR~
<br />D
<br />~
<br />~t!'rlr/
<br />'r1?U Tnc?T f4E 4T F'L,ANT (7L~..
<br />Y ~/
<br />, ~
<br />
<br />! 1 :J G
<br />•'j ~: i
<br />:PERMIT:: :'
<br />~~.: 9E PAP. .T
<br />'~' IC
<br />~. f,_POi;T ..#~'#N#k R#k kwk R ~#+Aw I k'MY 5~~~.
<br />- `
<br />.
<br />I'F 'I-NT ~,ZUi VALUC REQUIREMENT .
<br />.:3Lt3k~:itl~.. '~;~FTi7 ~t?X tGD ~~ ~ ~' ~ ••'•
<br />,'ILii_r TUT, AL SAMPLE
<br />E +##w+K ##*rrw •#rwkR
<br />2 7~
<br />~
<br />C' 1
<br />l r
<br />/ r
<br />~
<br />r : ~ ~ 1 ~ L V . I) MENT
<br />MEASUR p r
<br />(J /S /~j
<br />T
<br />
<br />.~!:,, ~ •~ .J . ~. PERMIT:'':
<br />~ ....
<br />..w#h>k1}: :: ...
<br />.~:.}'#~#}.e#.'A'
<br />~
<br />##
<br />~'ir~#~+*#ir :'
<br />iPT_ fd ~A
<br />T j
<br />~
<br />'1;ir
<br />+.. L.
<br />!;r.;
<br />°FLU.~Ni '!4U55 YALU%. :REQUIREMENT :.. ~':.:.:'......:.' '~.~..:~'
<br />...
<br />~~~ s++ ~ ~ ~'
<br />;.;i
<br />~T;;'..AY;,+. -...:~Y..'tX.
<br />t~:' -tGlt .
<br />ill +':V t.rt SA JL SAMPLE ++#+ww 0 yiy wwe+ws A#ww R, Rr.RRw
<br />Q
<br />7
<br />/j.~I)AL MEASUREMENT
<br />;;. 1.~., 1 .J L: PERMIT' ~ ##+#:+'+'..'. ~: ?:'PL~?T Y .S_f +.*wi## Rr+erww Rwat'#x s kfik ....l.l .::. ~_
<br />FF_Ur. iJT vdl'~); V1Lti :: REQUIREMENT ~ '.I'9 `s:T.~:~Fi.AX. ~. ItO=) rRk.
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ...PERMIT..:...
<br />
<br />:.... .
<br />.
<br />..
<br />. ..
<br />' ~' ~ ..
<br />... .......:
<br />: '.... .....~ .......
<br />
<br />:.
<br />t''~ :'.
<br />,....
<br />
<br />..
<br />
<br />:
<br />'
<br /> .. .
<br />.
<br />.AEQUIREMENT ~ .
<br />~::'.': .~:~ .:':..~ .
<br />. ~ :.:
<br />~ .
<br />~ ~
<br />NAME/ftTLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FA FY uNOEIt PENALTY of uw THAr I xAVE PEnsoNALLr ExAMwEO
<br />AND
<br />MILIAR VATN THE INFOIIMATON SUBMITTED HERON; AND BASED ON
<br />
<br />~
<br />l1
<br />/
<br />/~)
<br />/
<br />f TELEPHONE DATE
<br />/1 /,y ~ .Ij
<br />/~
<br />~j~~l~ ~ ~ ~1(TYJ 17 MY INOVIRY Of TNOSf IMDINDUK4 IMMEDIATELY RE~ONSISLE FOR
<br />09TAININO 7ME INFORMATION, 1 BFLEVE THE SUBMITTED INFOIIMATOM IS /
<br />/(
<br />~ !
<br />'~
<br />/
<br />~ Y ~. i ~/V
<br />Uy
<br />'
<br />`/
<br />TRUE. ACCUMTE AND COMPLETE. 1 AM AWARE THAT THERE ARE
<br />p\ ` ~
<br />Jtf
<br />~}'~
<br />
<br />SIONIRCANT PO/ALTIES FOR SUBMITTNO FALSE INFOMIATOM
<br />INCLUOINO
<br />~J O
<br />(/ ~ )
<br />(
<br />IJG" ,
<br />THE PoSSIBIUTY OF RME AND IMPRISONMENT. SEE 19 U.S.C. ! 1001 AND 7] eIONATURE OF PRMCIPAL EXECUTNE ~3~
<br />/ ~
<br /> U.S.C. L 119. ti-Mir ~rAr tlrr. mrvl.r mry irA.A rnu tm N t 10,000 AREA
<br />TYPED OR PRINTED wrmriruniryvieanwtWbrww.amenNa rrs aYwea/ OFFICER OR AUTHOR12ED AOENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reference s// ettechmenh here)
<br />.il ii'•_„- - S=~_ Pi1 r; l" j,~~9r "r la'~1~ 1'.
<br />EPA Form 3320-1 (08-96{ Praviou9 edition9 may ba u9ed. (REPLACES EPA FORM T-0O WHICH MAY NOT BE USED.1 ~ t / .' 1 ! 1 .~ - ~1 ~ , , PAGE i OF
<br />
|