PERMffTEE NAME/ADDRESS (include Faciliry NmnNLoconon if Di$erenq
<br />NAME --} -~ . ^ s „ - , .. _ . ..-1. ,
<br />..
<br />ADDRESS f T '.' . , 1 + •~ : ..
<br />• ~ ~ •
<br />+. ' • + ^ 'Q
<br />V ~ p~
<br /> (~J GIS
<br />
<br />FAC1uTV W ~
<br />LOCATION (~ ~
<br />
<br />
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) FOfRI AppreVed.
<br />DISCHARGE MONITORING REPORT (DMR~ r ,~ „ OMB No. 2040-0004
<br />Iz-+s) m~ e) Approval expires 0531-98
<br />(7 PERMIT NUMBER DISCHARGE NUMBER ^ _ ~' , r -. , ~ ~ ^
<br />MONITORING PERIOD '~T '~-~ "T^r v. ^: ,. +1 ^nrr\.~T •,~
<br />YEAR MO DAY YEAR MO DAY
<br />lzo-zl) (zz~z3) (zazs) Tte-z0 (ze-ze) (3031) NOTE: Read Instructions before fompletlng this form.
<br /> (3 CerU Ony) OUANTITYO OADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 46-53 9]•Bf 3e~5 4G53 54-61 EX OF TYPE
<br />f323~ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~) 'W~ 6g~s 69-70
<br />~. SAMPLE .-.. ~ a~ rsc"': ;.:r _.....: ,. ( ^~
<br /> MEASUREMENT
<br />U :)x1711 n 7 PERMIT.: ~~
<br />~~ •;;•• ~ .. ."t' ~~ 51+EQ $#'Q#' ~>11~ 5-
<br />~ ~' ,~,'.~".{(.~~
<br />'.1 ~ LL1:: i ^7S5 V4 L'1' ~REQUIREMENT """' ~. >^~^•R (}~~x~~~ ~~5~
<br />~
<br />~ i-1, ..
<br />„ ~.~ =€~~.
<br />
<br />•
<br />': . _
<br />:
<br />. y
<br />O.; L1 V1~ i ~1 ~. .. SAMPLE ¢r;eh'„!(j C x9•:x. .. ( 191
<br />~ U ~ b °' 1' -" MEASUREMENT
<br />r.^,.10 ^ ~
<br />' PERMIT ~ -..vaaae-¢4 ..
<br />`~~` awfi+l `n";~ .. ~ _s.
<br />e - '~*t -- ~x-~
<br />~ ~ -;4
<br />!l4L T!/.
<br />:YF[..a'.':"" .:n7i5 Y^ „"r REQUIREMENT
<br />~ yr-: ,-
<br />+ .
<br />_ . SAMPLE .:. C :: t' .r .. .Y ..:....;.:. ( '.. 91
<br />I'JAf! pE'CJYF[3~-'L' MEASUREMENT
<br />,:C"'nr 1 0 ~ pE~ t t ~rti~ PAP
<br />~ F TT4 ~;~ :*, fi+T '?
<br />a ~(~1fF/c
<br />{1 ' GRJ'$5 ''' ' REOUIREI'A `~'+~
<br />;^ - ~=~ I
<br /> .
<br />~ '
<br />.... .~ yIl A.. SAMPLE ~ ~~.:^:: Crs. ...
<br />x-art „ ( ~ ~)
<br />C Z S' l1 L Y ? it MEASUREMENT
<br />
<br />7 1 } ~ V ). 0 D ~ PERMIT =' p , . ..,., ~; :Y#
<br />A 4A1 u." IT. P 73r.;}py~
<br />'
<br />:; /
<br />~
<br />)Y
<br /> Y . .m.. ,
<br />~
<br />..
<br />... t
<br />. _ _1i „4_ Ira l.Ilr REQUIREMENT ~r-tC ~ "?S` i "71I ~'~ "_.T $.
<br /> _
<br />~ . -.; -
<br />..U'. ;.H, ea v ^[ o SAMPLE `F
<br />C^t` x..; ._xx,x ~
<br />,. ,., .. ..:_ ( T n'
<br />Di:~SGLY6D MEASUREMENT
<br />J 13'J ~ 1 '.f ') PERMIT
<br />~' ..,... to ., 9 ~'~~ ~
<br />` '~'`!". ""'
<br />~
<br />t; ~. C'C"I^, ~~^;5 VII rli )iEQUI EMENT
<br />R - - x' t`xi i='
<br />3f~A4
<br />IIY
<br />;
<br />~l41f RX ~._
<br />/I
<br />af. -
<br />'
<br />M{lk '
<br />te'
<br /> _ f -
<br />.
<br />_ , f. r
<br />., C Ll ., .. SAMPLE -. :
<br />7 K.L fiy .~.. .. ( , o)
<br /> MEASUREMENT
<br />n 3 ~ ~ 2 1 0 '1
<br />PERMIT ^° R 1#" :-
<br />
<br />/
<br />: G:tigr fR4--~=t
<br />- r.:. .._
<br />~~" ' - ~;,.
<br />-'r
<br />A~~r ,
<br />~ !~3
<br />'L'II /. '" .^l,'' REQUIREMENT - ~x j TN$3 yllt
<br />' ri L :9M$` y°
<br /> ~ : „
<br />-.~., NT.: :. .li
<br />~ , ... SAMPLE ': ct .:': 'G ~•r.„^.C ...::,,..~. ( 10~
<br />'C6Y `'^,? ?l. F' MEASUREMENT
<br />T 1~ 23 1 L' n PERMIT 4ArQr•)t t4 , ••~ :a rs DIY tk (!F"4'rtT bP pOTi ~` R$ / r,
<br />~.
<br />t' -LtJ:''i * r.n? :r' ;r' x.11 REQUIREMENT ~ ^"-'r 'r tdpR SY:; M :
<br />DlL [ CIX ' ":1T '7!
<br />!4x11![
<br /> . . .
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM IAW THAT I HAVE PERSO
<br />ATION SUBMIRED HERE NALLY E%AMINED AND
<br />IN; AND BASED ON MY /, TELEPHONE DATE
<br />
<br />?':ICf1A T'Ci .fII II`i 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 />//J~'/~
<br />~
<br />~
<br />~
<br />
<br />H TTYIPOTI TR9T1 Cc) 613 T'%1 rE: Y' ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMfI'TIN I AM AWARE THAT TH
<br />G FALSE INFORMATIO ERE ARE SIGNIFICAM
<br />N
<br />INCWDING THE '.
<br />~~ ~~%
<br />~~-.'
<br />// /'t~
<br />-
<br />97U-E70-2712
<br />5
<br />24
<br />g9
<br /> POSSIBILITY OF FINE AND IMPR
<br />3
<br />P
<br />lU
<br />d
<br />M ,
<br />ISONMENT. SEE 18 U.S.C. 41001 AND 33 U.S.C.
<br />li
<br />/0
<br />t
<br />Wd
<br />b
<br />000
<br />tl SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED nty up
<br />en
<br />18. I
<br />ens
<br />w un
<br />er
<br />ace srelufes may
<br />rrc
<br />e
<br />,
<br />a
<br />4 1
<br />5
<br />mebmum lmpdsonmerrt ol6eMeen6monNC end Syeera) OFFICER OR AllTHORRED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
<br />~. ~. i, i, (.• i ~ - -.' pr•r ~,I +.r v/~ ~ t. vc^I'~'1D 4%^T rrrr )~, f.T+rw _ ~~^ ~. ni~r t~~^. r /~ ~n'r r.. ^.~itT'V ^Tr I,^o,
<br />S L i ' ~ ^.:- ' .. / . " 11 .: , . t T ' w D a ~ '; _ ~ !' : ...) N y t ~ e) r I •. !- r r ., v , 4 .T r. P 1 .... ~ .. 4 r n ~ .
<br />~ ^.
<br />EPA Form 33267 (0&95) Previous editions may not be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) ,) n T ~ 1 / ~ ^ n „ , ~_ ~ p ~ V PAGE OF
<br />
|