|
PERMITTEE NAME/ADDRESS O+~d. FrdlyNa//xulm l/D/p...nq
<br />NAME !~ -. '
<br />ADDRESS ~~"''~-
<br />. . ~
<br />J t T /
<br />FACILITY
<br />LOCATION , ., ,...
<br />NATIONAL POLLUTMT DISCHMGE EUMINATON SYSTEM INPDESI Form Approved.
<br />OISCNARGE MONITORING REPORT (DMR/ _
<br />11-16 17-I9 ;' ; ,.. i ! ° , . ; _ ' C'f•~B~f•~o. 2040-6QCjEl4
<br />' -; ~ ti ;"~ '! ; 1 - Approval a%Piree 0 31-98
<br />`PERMIT NUMBER DISCHMGE NUMBER . _ '~
<br />MONITORING PERIOD '
<br />YEAR MO DAY YEAR MO DAY
<br />FROM I / TO ~ ~ ~ ~ !
<br />!7611/ I27-13I !1475/ I76-17I I28-791 130-371 NOTE: Reed Inerructlom before completing this form.
<br />PARAMETER l3 Grd On/yl QUANTITY OR LOADING 11 Grd OnIYI QUANTITY OR CONCENTRATION NQ FREQUENCY SAMPLE
<br /> M6-53/ !5461 l38-451 !4653/ 1546/1 DF
<br />l31-37/ EX
<br />MALYSIs TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !F]-6~1 !64681 169-701
<br /> SAMPLE ~ ~~ ~ ~ ( ~ I
<br /> MEASUREMENT %,r'~ '7,, 0 i;/',~ ~I ~,• t..
<br />, . PERMIT .. , . , ... .: .. .., - , - / , . - ,.
<br />~ ~ ~~ REQUIREMENT - ! ~'
<br />. i .i ... u it ~
<br />..... r , -. SAMPLE ~ .. ' ~, ~
<br />S
<br /> MEASUREMENT (' 0 ~/•~ rFC
<br /> PERMIT .., .. ...-. ,-. , ~. ..w., ..
<br />c.. ,
<br />i,° .
<br />A (.) I; 'REQUIREMENT
<br />... .. ..., ~ .; .' SAMPLE r . ~ . ; 1
<br />(
<br /> MEASUREMEN7 0 G ]~' .raL
<br /> , .
<br />i S .'. . '.` ? PERMIT ... .-,. ..
<br />... .... . .:... .. ... ..... .... ,-
<br />L
<br />~,
<br />` ' . . - ,i tt ? -~ :' ~ ~ ' REQUIREMENT ,~ - , I
<br />• , r 1 :: J F: i` ~ SAMPLE : f
<br />i ..
<br />a T M E' MEASUREMENT I . ~19 11 . ~ii.~ j~' ] f.+, ,
<br />.: U PERMIT . _. ~ 1 Y R L .'.. ? ., '.. ~ ;::.: .,: .. ..:: ._ . ". !
<br />.. : , R:! .. REQUIREMENT 3 !:~~ 9 A Y ; !: '~. ! !. F " / - .
<br />. 4 i'. P SAMPLE .. ~~. I 1 1 .
<br /> MEASUREMENT n O ~' 1:',
<br />., ,. PERMIT .:: R : .. , -~ ,I ] ~~ ', v - .: L
<br />.....
<br />.. ...
<br />._ .
<br />.. ~ , ,
<br />
<br />. .
<br />- , .. ,. ~ ... ,. I REQUIREMENT i '~ .: i `! ~ [ :1 C= .
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERM17
<br /> REQUIREMENT
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTI FY UNDER PENALTY OF LAW THAT I HAVE PERSONAILV E%AMINED MD TELEPHONE DATE
<br /> AM FA MILIM WITH THE INF011MATION SUBMITTED HEREIN; MD BASED ON
<br /> MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR
<br />I
<br />T
<br />F
<br />E
<br />TED
<br />j ~ 1 1
<br />,cLchard id. I'~URi Oll OBTNNING THE IN
<br />ORMATION,
<br />BELIEVE
<br />H
<br />SUBMIT
<br />INFORMATION IS
<br />
<br />S
<br />~'
<br />i' TRUE, ACCUMTE MD COMPLETE. I AM AWME THAT THERE ME
<br />TI
<br />N
<br />S
<br />T
<br />O
<br />C
<br />1 /
<br />r ~ ~`~,~ -_'
<br />~ ~ ~ /
<br />~
<br />~
<br />f
<br />~
<br />~
<br />~
<br />1~
<br />~.
<br />CP
<br />rC g
<br />F.'Ilt ,
<br />,~1
<br />T
<br />HE POS BILITY OF
<br />R EMD MPRISOHMENT LSEEN e
<br />US C
<br />M0 /
<br />' /
<br />t~ %~
<br />-
<br />-L%
<br />+ ( li
<br /> ]] . /
<br />SIGNATURE OF PRINCIPAL EXECUTNE
<br /> U.S.C. 1 1 SIP. lAnrkNr urNr rM« mnmr ^wY MsA.W fvya tp ro t IO,000 AREA
<br />TYPED OR PRINTED ulsnmu,,,wn Mllpe/A9MIIIIe of Mew«n 6menNaW 6YwU OFFICER OR AUFHORIZEO AQENT CODE NUMBER YEAR MO DAY
<br />DDMMtrv 15 RNU CXPLANAIIUrv VH ArvT VIVLAIIUrvD f/TBrerBOCB a//sReCnmen ES nYEe/
<br />Epp Form 3320.1 108-961 Previous editions mey be used. (REPLACES EPA FORM TAO WHICH MAY NOT BE UbED.I ~ -/ _ PAGE . OF
<br />
|