|
PERMITTEE NAME/ADDRESS (Include F'aciliry NamelLacaHOn IfDigerenq
<br />NAME . COY P 1 11 `~ (• rr ... •, r v ~ .. ~ ^ (T a 0 ~
<br />AD6RESSY L N q', 1 ~ l.': i (l ".'~ •:r ; c' ~ ; " . n r
<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) FOrrrl ApprOVed.
<br />DISCHARGE MONITORING REPORT (OMq; OMB No. 21W0-Ol%W
<br />" ~ ~ !) 71 c. 1 r, ~ T; n / ^ •• ^ ~ •• APProval expires 0.537-98
<br />"1
<br />PERMIT NUMBER DISCHARGE NUMBER c _ T •~• A T A ~ •~ ^' i
<br />MONITORING PERIOD r r c- + -, ri •~ r, +. T.1 "'1T')..I r- , :- v
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~'-+ ,1y ) TO ~ .1,{ ,.r .. .;~ •tT a.... .,P'T` --1 .-:. •.
<br />1--
<br />(zo-zfl (zz-z3) (1425) (zs-zr) (zaze) 13o-3f1 NOTE: Read Instructions before completing this Corm.
<br /> (3 Caro Onry) QUANTITY OR LOADING (4 Card w,y) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4&53 548/ 38-05) (46-53) (54fiT EX OF TYPE
<br />(32an AVERAGE MAXIMUM UNfTS MINIMUM AVERAGE MAXIMUM UNITS
<br />lszral aNaLrs15
<br />(s4s8)
<br />89-70
<br />..I, :I N:. { 1 t SAMPLE "'•`" xc:- tax xa- .. ... ( 1 11
<br />~ ~
<br /> MEASUREMENT a:5 35 aego 0 l
<br /> _ 7
<br />O iJ 0 1'I 1 0 IT PERMIT "^ ^. ~tilRRrgt6NF ~. ~
<br />~~ ~ ~!" ~X}P~ ~ • 41` f/ ~' ~ ~1Y~~ Y
<br />. -,
<br />' '• " : i' F!' ~ G u'T S ° Y M1 f ' 1 T REQUIREMENT ~~ '
<br />+
<br />ao
<br />~~ { _
<br />~- ,
<br /> ;_
<br />~`
<br />- :
<br />". SAMPLE ;xaaaCCe xxaaax -~•n~ ~-~ ~ > >~ y
<br /> MEASUREMENT ~~~~ ~+~y ~ t~
<br />DOaDO ! ? 1 ~~ O. =- 4 -~6gO4' r.^.. (y aw, ar,• ~P +(~ la 9t. ~ .~f-°
<br />~
<br />.. ,.'I .. ~T .. l~~~`; Vp. ^T RE UIREMENT
<br />
<br />.' - r. r:a^
<br />~1~» ,rJk~ ~"f ~~~.~ '11 :- "
<br />
<br />• ..per. -:e); ,
<br />'.l`.. J ~ A L SAMPLE -^? :',~ rn ", .ern r... ri....o (
<br />? of
<br />:'.I'LL:: !.DR:r MEASUREMENT ~ ~ ~ ~ ~~
<br />!)U:30 ^ D '! PERMIT ;e oav0 4fiY9t¢+X -.:a Ca R+RO'-0rCE ~',-':~ Hd'A'{
<br />... R&ritfla*!'*-
<br />:f": COC"P, t/TS H°I.^ REQUIREMENT - 4'}XOtr _ . (3A A~'% G-RII;.'t' ,~' 1`T/L ~ ~1
<br />:.U .USe :'l AL SAMPLE .'.:::r~<-~R Onr-,-_,. .: r: ,.,,t.. ,.~ ( I4~
<br />3
<br />-' ~ : • P "~ n ~ P MEASUREMENT b i ~ O ~ ~~ ~
<br />Q053 7 1 ^ i
<br />. ,. PERMIT RPPi
<br />, {~~ r+=~ 0Al
<br />~, ,;:r[: i ,,~ ~ i5 ~
<br />
<br />,.
<br />~~ . " "p
<br />
<br />
<br />~ f ~ ~
<br />
<br />
<br />`
<br />•~.
<br />- J .:T ;,^1`: i n~1 REQUIREMENT &. 4a ~. . l4=Ra "' :~~D~ ~~s O~~ ~
<br />*
<br />~ •(-
<br />C ~r <,.
<br />w s
<br />, . ,
<br />- /
<br />rl:,•I D~a i3T P[: ae''1. SAMPLE Q#9tYG;t ,;c r: .x t{ ?trt;}e•^ T "r;1
<br /> MEASUREMENT
<br />~I.ygS 7 (• 7 PERMIT ' ~` a+%>XR R- G40tG~r M. ~...~ :~4~'RRF# ;. ,~ ~ ~~~'~' ~ .'~ ~ ~'€'~t '. .; ~ ~~~~~ •x'
<br />CTr!'°~ '.;j c ter T l'~ REQUIREMENT m
<br />. r-'.hF `~~~~5 ('~ls.+ c~1AS ~~ ~1C hT./I. R19;+'t ri'
<br />s J..1 Dbr a'•: ?'";.' L' SAMPLE .•exa ~` n.zar•,x .~.. r.,~... ~ ~.~
<br /> MEASUREMENT ~ + I ~ ~b A
<br />n 71:5 ~ D ~ PERMIT Q CCr 01 - :If'#~A49r9l;1
<br />~ .t...: ,,:.~+fi+Ce4t4' ~~ :., ''1~~~Y'~ ~1f.~. '?` ~-`~R~'~~P s!"~ ~ R$' L ~R rr
<br />-i:'LU"i'T .r"'Tr .~. !.'I REQUIREMENT ~ +I::CC 3f11~~
<br />1(1Ti t11t62 ~' `. T
<br />/r MISN '
<br />s
<br /> . .
<br />. pt
<br />Jli, r, ~5 SAMPLE r•:•r rc~¢h Rrt ....tt .t ....:,tn^, r•:k sr :3',:r ( l01
<br /> MEASUREMENT
<br />(':'.!r~ 7. C ~ PERMIT 'b''04'G71P RfR4?4 P. •'.•; r. 6@s4>d'SYEt tt 9JI;M}lbltR 1. E) O$~l"~'1t : rf~: '...
<br />,'fL7F'."' :'!•1i5 Lr'- REQUIREMENT
<br />NAME?17LE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FAM FY UNDER PENALTY OF
<br />ILIAR WfIH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMIN
<br />IN; AND BASE ED AND
<br />D ON MY
<br />~' TELEPHONE DATE
<br />
<br />P
<br />IchRrd 111115 INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPON
<br />E THE SUBMITTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE, /
<br />~
<br />.
<br />
<br />Y
<br />l I•~
<br />C
<br />°
<br />[
<br />l
<br />t
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTIN
<br />I AM AWARE THAT TH
<br />G FALSE INFORMATIO
<br />ERE ARE SIGNIFICANT
<br />N
<br />INCLUDING THE h
<br />L.//>? ~ ~ 4~'
<br />
<br />g
<br />~
<br />8]Q
<br />1'2
<br />
<br />l
<br />ronrnen
<br />~ana
<br />J
<br />rv
<br />a
<br />- , ]
<br />- -•]] 5 z
<br />I gy
<br /> POSSIBILITY OF FINE AND IMPR ISONMEM. SEE 18 U.S.C. 41001 AND 33 U.S.C.
<br />utle litre
<br />b 510
<br />000
<br />d a SIGNATURE OF PRINCIPAL EXECUTIVE
<br />TYPED OR PRINTED ,
<br />s up
<br />en
<br />y~„1
<br />mm/mum Imp sonme 6 Mea~ months entl5 OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS AND EXPUWATION OF ANY VIOLATIONS (Aelerence all attachments here)
<br />T ,•rrtiAT LC`rI"i '^~ .-S `% T*L15'iL "lf T. (+' fL~C sp'1 \^PTY .T •.•y '' Cv +^_vrr l(1-t~P ~^f.r`T~ :V', rr.
<br />C%AI~r.'L~. ^,cc T. 4. x, P: THr aDn nn op F,tl C° p?~~c ncnrtTgPV~r •t+^~ .rtTr, .-r r•..~o__^cc ^r~n,•ynrc rt/i n"^'.
<br />EPA Form 332x1 (118-95) Previous editions may not be used.
<br />(REPLACES EPA FORM T~0 WHICH MAY NOT BE
<br />
<br />PAGE 1 OF
<br />~b
<br />t,
<br />
|