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PERMITTEE NAME/ADDRESS Qnchde Faciliry Nnme/location iJDij(erenq <br />NAME •,va..I ^ ,~, ~ -- ~- -- ~ - . <br />ADDRESSMr~•:I,'i )..~-~ :r•-.,...e ~,.. -,. <br />FACILITY <br />LocAnoN <br />~.TT'.: r'! t:T~ v, ;rr•i•.'Y~ rt:.'g9L 1.TYY <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESJ <br />DISCHARGE MONITORING REPORT (DMR; <br />r3-fe) m- e) <br />°\'1'177' SR nTn r <br />PERMIT NUMBER OISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ' "' - TO '~' ~ • <br />(36311 (1333) (31-35) (3&3l) (29-38) (30JI) <br />Form Approved. <br />„q ,,,, OMB No. 2040-0004 <br />Approval expires 05-31-SB <br />C rT y~ ^~~I'-T <br />•.r .. r. •T T~rLA f.rr +^ o.'~T'1?t r• <br />NOTE: Reed Instructions betoreACO leting this form. <br /> (3 Card Ony) QUANTITY OR LOADING (4 Cvd Ony) GUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (4B-53 (59-81 (3845) (4&53) (54-61) EX OF TYPE <br />(~-3~ AVERAGE MAXIMUM UNfiS MINIMUM AVERAGE MAXIMUM UNITS <br />(szal) Awursls <br />64-68) <br />6&70 <br />'L'.'~~ ~( _.. •!Ii i SAMPLE ( nj) .. .. ~., ..._.~ F~A'<y-:. <br />• ~' ~ U T N £ 1 ~; `. '; '. * ~ L a •. ! MEASUREMENT <br />~iDD57 1 Q C <br />- -PERMIT ~ <br />Rd P`J~F. <br />~R R~`$T`F p(d# <br />5 ,. ~-> ~ # Allt.- <br />~!~ 6h <br />P.. ~~ #~= <br />'~-" ; <br />'~'(;"1F <br />-ct':.UiN' I:.V•1SC yxI rr _REQUIREMENT- <br />~l'~E~ <br />t. <br />~ <br />~ <br />DA[bX''. +r[' ~ ;__-. -'i +t+ - ,`,.. C ~ r`~+. <br /> , <br />- <br />.: <br />_ )'.~fl'Sr '.~)*rt. SAMPLE ~wr'S30# r.^-'Y7h4 !r+>'k'::~r ( 1 "') <br />f.• ._ :. ~ 7 I. Y ~ [: MEASUREMENT <br /> '~ PERMIT - T ~':~, <br />°.. pAC: -~"9~~R :'?= . f; PI~,~ ;:• •t "v <br />~ r> ~R~`i <br />=..°L 11 ::aT GP~;S YRL'?° ~REOUIREMENT r <br />"~_ _ - - -~ r,-;e ('"- - :~.~{)O~-1[~-",. :~ <br />.11~. '~xtf ~ r~~T, '~`~ }J,j~~ ~. ar e~ . <br />t.-._ I. SAMPLE `_'.`•q-t ( "iJ) ... Syr,... rr~ ~~......•, ~. <br />'! I .i ' f A L MEASUREMENT <br />L':.iuf, L D "D .PERMI Dn4 NEPyAT Fi=1 °-. QIb1$!4+S ~- 4: ¢.*ik ... <br />~~ ' <br />°'_Li)°(:P CRDS$ ~1^ L'' REOUIPE~)•1T. . ~~5,"I ~bK ^t1=J ~t `~'4 .~.A.~ t;r i .T `: <br /> SAMPLE <br /> MEASUREMENT <br /> .. ;•: .ERMIT t. ~ g'~ ~ ~ - cad ~+tiy .~ .~, :,, <br /> . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - <br />- - - - 3 ~ I =~' <br /> REQUIREMENT <br />. <br />, <br /> <br />._ - i _-'.' <br /> <br />r. <br />- <br />• - ~` <br /> ... ~: <br /> SAMPLE <br /> MEASUREMENT <br /> --?PERMIT ~ - ° .. .v~•'._ ..~ .)-;~,: .~ ~... <br /> REQUIREMENT - ,y rs ~; <br /> „ , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' <br />§~ <br />~ <br /> REQUIREMENT ~ ~ - „ <br />t <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERnFV UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO <br />ATION SUBMITTED HERE NALLY EXAMINED AND <br />IN; AND BASED ON MY t TELEPHONE DATE <br /> <br />r')Cherc; I'?III9 INQUIRY OF THOSE INDIVIDUAL <br />THE INFORMATION <br />I BELIEV S IMMEDIATELY RESPON <br />E THE SUBMITTED IN SIBLE FOR OBTAINING <br />FORMATION IS TRUE ~ - ,~.~ <br />/!J <br /> , , AAA <br />/ <br />~ <br />-, <br />nt7 ~L'P <br />F- <br />nvironmental i ACCURATE AND COMPLETE. <br />PENALTIES FOR SUBMITTIN I AM AWARE THAT TH <br />G FALSE INFORMATIO ERE ARE SIGNIFICANT <br />N <br />INCLUDING THE / <br />~~,/ ~ <br />~ is ~ - <br />97D-A7 D-ZZ'TZ <br />S <br />Z4 99 <br />. <br />x. POSSIBILITY OF FINE AND IMPR <br />§ 1318 <br />(Penaties under these s , <br />ISONMENT. SEE 1S U.S.C. § t001 AND 33 U.S.C. <br />tenrtes mi <br />IncNde fines u <br />b 510 <br />000 entl a SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />ry <br />p <br />, <br />maximum lmpnsmmerx of heMeenamonths end5yaars.) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence 811 ettecnments nereJ <br />~1 i. ~ .. ^ -. -. r~' )T ^~. ~~_ )~ ~o.,p\R rT~w. .r+T,~ •T•IT^^ .--r i•(.n~ w-. T~w .gym -.T ~,.Ty .~.- T•r--1 <br />-TA LS ~1^. ~ /~ ..n ~T wn .r~ ~ _ -••a: +lr r•r •lr 7. .-r..+T-. nA .7r 0.rrT~. ){. t• <br />r <br />EPA Form 33261 (0&95) Previous editions may not be used. (REPLACES EPA FORM T30 WHICH MAY NOT BE USED.) ,t n ~ ~ ~ ~,t o ~ rl 1 ~_ ~ ~ ~ ~• PAGE OF <br />