|
<br />PERMITTEE NAME/ADDRESS (Include Fucl(iry Nmnr/L«aron ijogomr/
<br />NAME _p~, j,3 ._ rt. ... v '_',r ,nom
<br />ADDRESSN ('I cy~ t ~ ., r 3 ^ r. ~, ~~ _ _ .. rc ,r
<br />FACILITY
<br />LOCATION
<br />::,7 °. :7R~),~ 0. ~-7~ 'r .i''1!f y^r rya
<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDESf
<br />DISCNARGE MONITORING REPORT (DMR;
<br />(z-,s( m- s(
<br />^'J '1 '?]71 tq rln~
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ''" TO '"
<br />(zo-z,l rzz-23/ (zazs/ nF1a ne-z91 ta>3n
<br />Fonn Approved.
<br />,. , , ., .. OMB No. 2040-0004
<br />_' Approval expires OS31-98
<br />/"i~.~ ,
<br />NOTE: Read Instructions before completing this form.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 4&53 5467 3&45 4&53 (54-87
<br />Ex
<br />of
<br />TYPE
<br />(3z-37) AVERAGE MAXIMUM UNfTS MINIMUM AVERAGE MAXIMUM UNITS
<br />fezai) ANa(.rsls
<br />(64
<br />-
<br />s
<br />8
<br />6&70
<br />~~-' SAMPLE
<br />M .-R::f :: r-':: . ~' "/r~ /-~1 .. .. pY.. n+. ~
<br />I
<br />G { • 1, /
<br />y
<br />/
<br />j
<br />~ //~r
<br />
<br />EASUREMENT / • 1' I 1 /"N rl~
<br />liChCC 1 D :1 PERM(T
<br />! _
<br />~ r,Y^-r i :•~ .` tJ ~,r1
<br />~ :. `
<br />L l' : , i i; 3 7 : , y ~ L I I r _
<br />.
<br />.F(EOl11REME
<br />NT "o z'- ~.., #... t ~~~ r, .:t 4 , )
<br /> . ., ..:..:.., ~
<br />,'.' u - • .'. . !'. ..._ SAMPLE c i:. 40 :. : ..: :,r;: 7 h { , c )
<br />
<br />' MEASUREMENT ~~ ~~ u
<br />)II ~.4't i~ ~ !1
<br />PERMIT .OO• !f%Y+ yt„ Rt 1Rq?
<br />i~ 'F,"
<br />~'~ 'F+'
<br />~
<br />r -
<br />r ..
<br />_ ._ :. :1h`''NT~ °~-..~. REQUIREMENT ~ #r's'%
<br />-
<br />•i-~h ~~~
<br />Q~~ 4l .. ~~~. ^.r
<br />..~f
<br />('
<br />~ ~
<br />` .
<br />.. l..i u~~ Ob[ c ~..
<br />• SAMPLE
<br />MEASUREMENT rr :. rp .: ~^: ;rt ~.r.:.. r...
<br />D { ~K1
<br />~
<br />~ 3 nD
<br />~
<br />A
<br /> r I
<br />JL
<br />i
<br />
<br />~
<br />'
<br />°
<br />r~
<br />= ~
<br />'
<br />.
<br />- ~. '
<br />/, r r t
<br />f
<br />LUFkT GR0~9•; ~q.., NT s
<br />' .~e
<br />.ae
<br />.. .
<br />..YtR :7~~ -~~'$~''
<br />..
<br />. ~~ 1~ ••T /T, !1t,3~'!~" ~,.. ~_
<br />_ L .. `f K C SAMPLE „
<br />.,r,.,i-, D 'FR.- nn #d'.::`- .. ~
<br />...t .t .~ ( 1 ~) ~
<br />
<br />
<br />"
<br />MEASUREMENT ~ Nl~ /~~ ~17
<br />i 0
<br />, ',5 1 D D r.
<br />- PERMIT *'
<br />~, b
<br />' rsc+s ~ o~ecs
<br />i7
<br />~ "s^ ~_~ .
<br />`~4
<br />)~k'~"
<br />-
<br />:'LI!t~iT GRASS P4. r.ll' REQUIREMENT ,
<br />n,
<br />* +~a Orkh^ - :=4'~ ~y ,',y, ~y~. .
<br />~` .
<br /> .•
<br />~~:.~ 171 VU "{
<br />' ~' T P E II T N° y° ^ f f SAMPLE
<br />MEASUREMENT
<br />O I p~-S ~
<br />. ~ Sao { n~) .r: :txe r• .;rv!y+: •:y ~w.•,~t:: •.
<br />`I/~v
<br />~
<br />lti~
<br /> ,
<br />~ D I' - D 1 P ~ , -^~~~ERMIT . P R 3
<br />+*~ ~ 4 ip IF R '~ - :.°p°~~'~: ' ' - 4# Rr-~'fi q AA ,. . -. ~?' - ~'~, , !tS'~7~, -
<br />~F°LUSN? 3P. `;S ~d4LR, 'R~UIREMENT 1QD~ S~
<br />$ ~
<br />~;~1} 11';<
<br />' Mrn ? 4#'k;~ 3
<br /> . . ~y
<br />NII ..:t' ~': SAMPLE aiTaa ~ 9y) R..: :t .. #>z~ rY-F
<br />L
<br />t' I +': A L MEASUREMENT O Q v'l
<br /> ~U~
<br />i1: 11 r,h 1 (' " .'-.PERMIT -,- .~'-. -..
<br />~ p5=1 ' .R@~;-. . ## 11EfF.: ;.p~ ~{: 3... :~' F.?a`R1`:'I 1~i1~ ..
<br />.'r': '-Or: 1:T ~u')5:- ^!C(tt REQUIREMENT t~l g.~ nrt
<br />x t:n=(: ~ r, ::: •: . ,'*,;
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT ~ ~ ~
<br />~
<br />~ ' ',t+Et
<br /> REQUIREMENT - - ++-
<br /> ,
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATON SUBMITTED HERE NALLY E7NMINED AND
<br />IN
<br />AND BASED ON MY
<br />-
<br />^~ TELEPHONE DATE
<br /> INQUIRY OF THOSE INDNIDUAL ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING ~ %
<br />~
<br />F,icha rd i' ~~(()~
<br />THE INFORMATION, I BELIEV
<br />E THE SUBMITTED INFORMATION IS TRUE ~
<br />i
<br />may
<br /> ACCURATE AND COMPLETE. ,
<br />1 AM AWARE THAT THERE ARE BIGNIFICANT ,
<br />,
<br />~
<br />%
<br />~
<br />'
<br />~
<br />~
<br />'j
<br />~ r
<br />IlF
<br />~ :T1~ Y
<br />Y0i1
<br />u T1 t: i ~
<br />:
<br />~
<br />PENALTIES FOR SUBMITTING
<br />FALSE INFORMATION
<br />INCLUDING THE i
<br />r
<br /><<..
<br />• ~-
<br />%'
<br />„ o70-E70-2712 5 24 9S
<br />:
<br />.
<br />.
<br />1
<br />~
<br />7 , ~
<br /> POSSIBILm/ OF FINE AND IMPRI
<br />(PansNes under Mace s
<br />4 13te SONMENT. SEE 18 U.S.C. 41001 AND 33 U.S.C.
<br />mhrtss ms
<br />Inc/utlp tires u
<br />m f10
<br />000 rotl d SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED .
<br />y
<br />p
<br />,
<br />msximum ~mpnsonment olSSMeenSmonW rotlSyesrs.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIULA I IONS (Hererence ell etrecnmenrs nereJ -
<br />L~:i1L'4`r.' ~,;Li.c r~..Tl r~ ~''+Ir"^ (!. _l_ •Dfl '1"la y~nyou~ ~q_ .. narr•n ,.v,,,,. ..- •-T.a*.,~:r,~ ~r~. r. •.
<br />• 1#A ~•~:~ ]n .n"t' ,i ._. ~/ ~I• - inT U,...~cVp~;. 7f[, r •'(±tP^ _~^r crlnn•~.:T-c• [•~, nr 7~ ,-~TlT J)V ,.; MO(T•,. ^~
<br />EPA Form 33241 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T30 WHICH MAY NOT BE USED.) n ,~ n ,r i ~ ~ n r, It T ~- T r ~ n PAGE T OF
<br />
|