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PERMITTEE NAME/ADDRESS (Include Facility NmnNLotaean (JDI$omr) <br />NAME <br />.. ~ !' n L.r . ~ i ~ 1 '! '~ ~ 1. ' I <br />ADDRESS , . n ° F :. " : '~ .` <br />FACILITY ,. ° i ~' .: ! r , b .. i <br />LOCATION <br />NATONAL POLLUfANi DISCHARGE ELIMINATION SYSTEM (NPDES) FOfm ApprOVed. <br />DISCHARGE MONITORING REPORT (OMR) OMB No. 2040-0004 <br />"T i <br />PERMIT NUMBER DISCHARGE NUMBER ( _ +) <br />MONITORING PERIOD ' I ~ . ' ~~ .... ~' :i L'.: <br />YEAR MO DAY YEAR MO DAY <br />FROM rl7 TO J1 v`_ 3~ ~ ... -'r'ii _~~ t%: <br />. ~• • vv,r a-~i ., :. t .. .. __.~ .. ._. .. ... .__.___.____ _ <br /> GUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PAR <br />M EX of TYPE <br />A <br />ETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~~/S <br />' SAMPLE .....::: ^: •: .. .. r r- ( :.: ) <br /> MEASUREMENT <br /> <br />,. <br />J : ! ~r . 1 J = `'gip' ~"~- ~' ~ e ~' ~ <br /> <br />_ f ;~-'' ,.,,~ <br />~ L a `it;gr '~ ~' <br />~~ ~ ' ~ ~!I$~~~`L <br /> <br />• L l <br />~ Y A <br />' <br />REQUIREM~`!T <br />~ <br />~~ <br />- , <br />~ ~~' <br />e .. r <br />~ <br />~et r~ . <br />t"~ <br />x <br />_• <br />, ., : <br />. t <br />t;~ <br /> SAMPLE <br />SAMPLE <br />~I <br />SAMPLE <br />SAMPLE <br />SAMPLE <br />SAMPLE <br />a:m. <br />K. ' <br />~.. <br />~; <br />_. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Ceniry under penalty of law that this document and ell eMChmenis were TELEPHONE DATE <br />prepared under ory direcllon or supeMSlon in acoordence with a system designed <br />m assure that queliAed personnel properly gather Bn0 evaluate the Inrormaeon !~ `~~ <br />~~. Gordon Peters submibetl. Based on Inqul of the person or arsons who marry elves ~ <br />my ry p g ystem, .t I' 'd7'1_g~y-4401 61 Or 25 <br />Prf!5ldent/General Manager orihoseP~rsonadlrectlyresponambforgatherkgtMlnlortna(ian,thelnlormelbn <br />submbtetl Is, m the best of my knowletlge end bellel, true, ecwrete, end complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br />l em aware that there are signiecem penelaee ror submitting lake inrormation, OFFICER OR AUTHORIZED AGENT <br />TYPED OR PRINTED Intlutlind the possiblliN elfne and lmpdeonmem ror knpwing vlolatipne. _ CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />r [ I t' l; . U F F i { : ; ~ f ... ". `, ^ L ; ..) iii . .. - ' ..:i ' A ri ... <br />A :. l ' r <br />SPA Porm-3320=1 ~ R~V~3/9 Previous editions may be used. '" ` ~ ~ ~ ` ' ~ ~ ' - ' r THISrIS A 4-PAtiiT FOR IlG2 ~ ~OF - <br />