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<br />ERMITTEE NAME/ADDRESS (Inclode Faaihry A'amrJGocmion ijOrBerenU <br />NAME NATIONAL POLLUTANT DISCHARGE ELIMINATIQ $VSTEM (NPDESJ Form Approved. <br />S C it t. C A C (~ A L C C f F 11 F Y 'DISCHARGE MONITORING qEP ~ (pMR <br />~.'c <br />z <br />1s <br />3s <br />I ti U P <br />T OMB No. 2040-0004 <br />ADDRESSD kA w E k D ( <br />- <br />l <br />L721 l <br />m- <br />~" 16 A . <br />(~Ui:fl NGj Aoproval expires OS-31-9fa ,f <br />flAiDEN CU 6.LJY IT NUMBER ISCHARGENUMBER F - PIlFL FICU77 <br />FACILITY MONIT INGPERIOD CI]CdAbbE ']C hCEEE~,SCi GU1CE *~ <br />LOCATION A T G a k ~ '. ~ <br />' <br />" <br />' <br />CU 81 Y MO DAY = YEAR MO DAY <br />~ <br />;. t:• <br />r-9. 630 FROM ~ ~ ~ on# <br />'~=rt hG (]SCtl/pGF ~ <br />A TT K : G <br />H „Tp <br />. <br />UD E %0 G N , G ~ }t ((/ M / 6 E H rzo-sn .7 sal na. rzs zn ne zsl !30311 NOTE: Reatl Instructions before completing this form. <br />PARAMETER aTd OnryJ QUA NTITY OR LOADING and Onry) Q UANTITY OR CON CENTRATION NO. FREOUENC SAMPLE <br /> - (46-53) (54-6/) (36~45J (46-53) (54-6/J E% OF TYPE <br />(32-37J <br />SAGE <br />MAXIMUM _ <br />U ~ <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br /> <br />Iszc31 ' <br />ANacYSrs <br />(64-661 <br /> <br />(69.70) <br />P`( SAMPLE tP. ~ 4Efil0 O:r, .r ~,Y ( I4j <br /> MEASUREMENT <br />OU4UU <br />1 U 0 t-,"PE IT, #' :, ~ a <br />~ ##•'.~ . .}~; + ~ ` <br />l;FFLUEkT l;kU53 YALU h~)H'T . :. 4 <br />•• itt# ~ •!;Y`E6! , SG ~ <br />SGLIUS, TO ~ ~PLE ~'~°~°"^ oa~ <br />a ~ n## ~ ( 75) <br />5USPE:NUEU MEA$ EMENT <br /> <br /> <br />EFYLUi&T GAD.55 YALUt AE©UIR ,~~ t ~,I; ~- "~ <#~C `~,~~ ~~' ~a~~IG ~1~~-'jr;~{E l!G/L 8~-M41 `~ <br />SGL , $ A SAMPLE ~ 'Y''~ ( •_ <br /> MEASUREMENT <br />0 ~ <br />US4S 1 U 0 PERMIT !' ~ ~'~'~` <br />+! <br />~:~ <br />'" <br />p • <br />/ <br />hFFLUE.~T GROSS YdLUF AEQUIREMENT ~~N ~.:~ cxc.: '` ~ =~~,,~ ML/I ~. ~M4g~ .' <br />ItiON, IOTA SAMPLE rA ~ 4K"~- Lfi~'~ <br />(AS FE) MEASUREMENT ' ~'= <br />• <br /> <br />U <br />4 I, <br />-. <br />lU <br />S 1 0 0 ~ tea ~ ~ " >:~ <br /> <br />EFFLUENT GROSS tALUE <br />QUiREtv1ENT <br />~ <br />• <br />taX~o ~ <br />300 /t6: ;, <br />/ <br />t rd~ <br />NG/L <br />; <br />~ ~tl <br />; <br />IL ANG C:RE• E SAMPLE Cot, ~'tl= wr>F <br />a:.'= t z:o<~vY'~ ,o bLV , ( j <br /> MEASUREMENT <br /> _ <br />U3Sd1 1 0 0 P'GRMtT tt10 tt stt~ tttt# 0>0#Att . - >i/ <br />EFFLULI~T GN095 YALL AIQUIRENnEN7` ~; <br />.- ###= ~~'~`,'~~ ~1lC/I ~s:c_ ~i~117 <br />FLOG, N CORD IT OB SAMPLE 1 3) '~ ~' =#n##>u , <br />TflE.U TP.tATMEMT PLA/ MEASUREMENT <br /> <br />SUUSU 1 0 0 t~:P~pM4T ~/ 0&T , 0 9o t~tit ooa S4 <br />EFFLUENT cflOSS YALUE ~,~OIlIR$MENT 306/ 1XtI, -, ~#~~v FGC #ia# ~ I` '' <br />SOLIDS, SOT L SAMPLE ~A"~~` ~ ¢~ mo ( I <br />i)I:,SGLYEU MEASUREMENT <br />' <br />IU29S 1 U 0 <br />~ PORMIt' t Ott toe ;wtot T Gil/1 aE fi A/E . <br />EFFLUENT GROSS YALU ~4Ui~lEIN~NF- ~~ ~°~ tnom ~ ~ ~gTp <br />/ ~, ~ •~~. <br />AAi~I NG/I <br /> - <br />- - ~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND <br />AM FAMILIAR WITH THE <br />NF TELEPFIONE '~ DATE <br /> I <br />ORMATION SUBMITTED HEREIN, AND BASED ON MV <br />INQUIRY OF THOSE INDNIDUALG IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />~•1 <br /> THE INFORMATION. I BELIEVE THE SUBMRTED INFORMATION IS TRUE. Ol <br /> ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br /> PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING THE <br /> . <br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE Ia U.S.C. § 1001 AND 33 U S C. SIGNATURE OF PRI IPAL E%ECUTIVE <br /> <br />TYPED OR PRINTED § t31 e. (Penalties under these stables maY inclutla lines up ro ff0,000 antl or <br />maximum rmpnspnmam albeAVeenBmnnths end5yeers <br />) <br />OFFICER OR ALR ORIZED AGENT <br />~ <br />NUMBER <br />YEAR <br />MO <br />DA <br /> . E <br />a.vmmux I o nrvv urir~rvr t Irv ~r nrv r vlvu+l wno (neTerence an anacnmenrs nere/ <br />I'SS 6 IHuN LIMITS Y1L1 P, t: YAIYED 6 SETTLEAELE SGL]CS LIMN APPLIED FG <=LOFk,24Eb FHEC]F I~Etl7.F 755 6 <br />LkOM LIMITS G/IYED FGb )lOTk,14flH PRECIP EYFMT SUF,7HCT 70 6UFDEN OF PbCCIi IEI I.A.Q. CIL 6 GBYA~tl - SEE <br />T u T TT- TDS-1'tli~"'ildr, - T E.3 / <br />EPA Form 33247 (08A5) Preyidus editions rn8y nqt be used: (REPLACES EPA FORM T-40 WHICH ~MAY~ NOT BE USED.) Q~ 14~~ 99 0 E ~ 3 ~ 16 S 3 PAGE ~ ~ OF~ <br />t <br />