|
PERMITTEE NAME/ADDRESS (lndude Facihry Name/Location ifDifjerem)
<br />NAME FiCr.EI'slFt PSCCEESIti:., liC
<br />ADDRESSN ~ {, F. L K :1 I h E
<br />1311 ufiEhTYCCC CFIVF'
<br />1VAt:5YIL1E Ih 47711
<br />FACILITY
<br />LOCATIOtiI t. E T C t. C G 8 l 1. Y 1
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESJ Form Approved. ~
<br />DISCNARGE MONITORING REPORT (DMR~ OMB No. 2040-0004
<br />2"lel I"~ s) •` 1 F L n Approval expires OS-3T-9R ~,
<br />,~ ~ GUFF cE)
<br />PERMIT NUMBER ~ DISCHARGE NUMBER } - F I M ! L L d r'F ~~
<br />' MONITORING~PERIOD C G T: E $! I C _` C F A G E 9 C E C A[ C C E
<br />Y -.~ ~.TvIO DAY YEAR MO DAY
<br />FROM ~ `I ~ TO U sU abO /C CISCE!AEGE ~X~ '(~~
<br />(z113) (2a-z5) (z6"2]J (IB"29) (3691) -~ Read Instructions before completing this form.
<br /> (3 Card OnIyJ QUANTITY OR LO G (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61J EX OF TYPE
<br />(31-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />fszc7l ANALYSIS
<br />!s4"sB)
<br />69-70
<br />'GU, ~_I.AY SAMPLE •:+~Va04 ~S:`>4Y4 000000 ( I5)
<br />(2 :• 1' ~ G . C) MEASUREMENT
<br />'C.111; ~ U C ~k1";,
<br />_. ru~E!]( 000 041:00 OCd .. .000 ~ "~ PCbT~ r"' ~. I ~.~'~
<br />. ,:~~" FAQ..: .
<br />[sl:rF~c~:,iHC:; ,;nPI7 1
<br />C1JkY 8~ ~ ;Tfla~ '~~ = L~ 11~~'<~ ,
<br />` k;~~g' f'r7I X14
<br />:1 SAMPLE ~ 000iTG Lit}t: '..:~~ :C::iyO I Is)
<br /> MEASUREMENT
<br />:)u4uo ti U o ~ ~ t~' ~ ~ ;>;: B 4A440 ~ i51~'.
<br />ISInf'LCT,FNC'c CMFi7 II~IENi ±: = `
<br />. Y:;>: ~ ~ U
<br />~ .L -~P
<br />LLIi:~, TCTAL SAMPLE •~'}00 >3;O;r>::t 9000 ( ]S)
<br />is ~ F i. .'1 L E ;; MEASUREMENT
<br />c53o A t tamc4 00 >G#o : r,. bLCBT '• B$;# R / Btg, ,
<br />I:LN}«1,PAC:; .:Y.FLI 'P'13`' "~'~- +0:: 9~~: .
<br />Mg-'~`~ ~ 'G/L ,
<br />'IL r.kC C,h EA:,E SAMPLE 4?C~^r t5t y. .9 V x•040_ 04f,0~ ( ]5)
<br /> MEASUREMENT ~ C7 (~
<br />3~d1
<br />U U t0 1~' >6~0 ~ °:~# ~N Rj~'
<br />A PERMIT .
<br />i a l h F :. C:, I R C S C C F L 1 'E3E'O111k~~AlEk3~ t•,
<br />..,
<br />._~.:
<br />;~s,: _
<br />,
<br />L(J'a, iY CGNUUIT CF SAMPLE 1 L'3) 0000: 8't 000 00CKt'0
<br />16nG '.."k i.AT:~E67 i•LAh2 MEASUREMENT
<br />
<br />:i~LhFLCT,PFC5 CI^FIT ~ ~;.' ~~ ~ FCL `` r
<br />~~~
<br />.tz~
<br />C.LI7CF.f', FECAL SAMPLE CCOr"•'vil ¢;'1040 :.C 0009 1 l:)
<br />t. h E !. A L MEASUREMENT
<br />/u05: A U 0 ,..
<br />; ' ~ w0=~ C040-! "~ ~ ~~,, ~>I SFr
<br />~I~Ih'F'EC'i
<br />CC[I1
<br />PBG' ~
<br />~4i Z~'' '~'
<br />w '
<br />:3V b0L"4 '~
<br />~ C(!I '~'=,f
<br />,
<br />_ . ,
<br />~ „
<br />.; ., ..
<br />~Ii AhL" GkEASE SAMPLE °~'";'
<br />°;` 1 9y) ^'''r?:10 ~ 04000: 4Ltt0y.
<br />J I L L' F L MEASUREMENT
<br />1, U b b A U C -::~y ~ ~ ;. r' ,~ , .. . E `_ = [ ~IF -9
<br />" "i eys ,~": '~ w
<br />, 0 : y, >~ ~ ~. ~,];~ ~ .,
<br />'ItiIhF'ECT,PnC5 ChFL'i •9fi~ '( t#r• ', . (+l-C .,
<br />r"i;' a .~ 3
<br />; 4tti
<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICEfl I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO NALLY E%AMINED ANO TELEPHONE DATE
<br />AM FAMILIAR WITH THE INFORM ATION SUBMITTED HEREIN: AND BASED ON MV
<br />INQUIRY OF THOSE INDIVIDUAL
<br />E INFORMATION
<br />I BE
<br />T
<br />EV S IMMEDIATELY gESPONSIBLE FOR OBTAINING
<br />MITT
<br />D INFORMATION IS TRUE
<br />E TH
<br />SU
<br />H
<br />,
<br />LI
<br />f, T r ~
<br />ACCURATE AND COMPLETE. ,
<br />E
<br />B
<br />E
<br />I AM AWARE THAT THERE ARE SIGNIFICANT [_
<br />`. PENALTIES FOR SUBMITTING FALSE INFORMATION. INCLUDING THE
<br />1R N q (~ F' POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1B U.S.C. § 1001 AND 33 U S G
<br />S[GljATUR
<br />OF PRINCIPAL EXECU7~VE
<br />- 1'1
<br />§ 1319. (Penalties untler these stelmes mey include lines up ro E10,000 entl or
<br />PED OR PRINTED meaimum:mpnsonmem al beareen snronths entl5yoe/s.) pfiFICE OR AUTHORIZED AGENT A
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attach/nen[s here) '
<br />.it, L'AY AYEKAGE I5 FIChEST C.CATHLY AVG• GUSI-G F'EF]CC ACFCbTEC. 011,6 GAEASH -,SEE I.E•].t~ F. 5.
<br />EPA Form 33201 (08-95) Previous editions may. nnpGe Used ( @4.AGE5EPA~FORM T~0 WHICH MAY!FJOT HE H$ED.) ~ .PAGE OF
<br />
|