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PERMITTEE NAME/ADDRESS pui,LFssgNadLoc.uw ypp .,,p <br />NAME -. .:. .'v_,.u _..'~L %('.Y <br />ADDRESS ~ •~ ^ r "~ ~: <br />NnL~~~N CU dlD3~ <br />FACILITY <br />nTCh: u• 0•.17 r;.JHY~ f~E'a. I~aa. 1i1 .', t. ,. .. <br />NATIONAL POLLUTMT DISCHMOE EUMINATION SYSTEM INPDES) <br />DISCHARGE MONITORING REPORT lOMR) <br />11-16I 17-19 <br />CCU^a~t21 COP <br />PERMIT NUMBER OISCHMGE NUMBER <br />MON170RING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM L4 'U i. TO '~ ~ C t .: 1. <br />ration i vue. 5 nefn nR.Pm ranAn <br />Form Approved. ' ~ <br />r: - ~ ,. '~~ i T- ~ ~OM~Nor~2D4e; OrOOZ <br />(, ., ~ Approval expirPe OS-31 8 <br />"R) ls~ rJ <br />. - Frr-L . <br />".1'C. <br />NOTE: Raed Inetruetiors before eompletina this form. <br />PARAMETER 13 GTO OnIYI QUANTITY OR LOADINCy l4 Grs OnlYl QUANTITY OR CONCENTRATION NQ FREQUENCY SAMPLE <br />l31-371 146531 /54-611 /38-451 /46-53 164-671 DF <br /> <br />AVERAGE <br />MAXIMUM <br />~ S <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX <br />Is1-s]l MIU.YSIS <br />164-6B1 TYPE <br />169-701 <br />".. L.~F.C~: ;~id."^[. ~r, .i :' <br />a <br />! <br />~ <br />- <br />L A / H :1 SAMPLE <br />MEASUREMENT ... .-. .. :.t ~I~~ ;~{±u}: ': t:}t{::;: :3 <br />( ~ /~ <br />~ <br />'1 <br />.. <br />.. <br />, <br />~ <br />r. r <br />l : V („ <br />'I V c <br />i C ~.i c 1 U PERMIT ,. ~ .. .. Ca ~>;:;: ;.`•:} (..^..:; }.3 . .:; C>?p + °} <'%~4'' _::'- 3'f "tL Y ;• K 4 c; <br />.._ :':I `• ~'. r'i5 lrFLO~ REQUIREMENT .?'I :: ? ej.:N YRLL'e Ci. !. f <br />-, ::lt _.:i :i~ASHE 7L"nY <br />~.H i. 'I.';r, `~ SAMPLE <br />MEASUREMENT <br />.. .. ..., <br />.. .. <br />... ...~ ... <br />.,.. <br />/ <br />`I~~ .;o••:.^. <br />.. <br />.:: C: rt: ~ ~j~ ~ '~/, <br /> <br />- V <br />vu <br />'i 1. .';•l. ~ '1 PERMIT ::: r.:;: +Y{:-.: ~: r~Y :=t,:.r r.: CC: ~.3 0{~:C4a #:`t:;:~C rER- :'TWLY '. :2Ar. <br />.. '.: U " " i '> .. ~' !. ,. 'n REQUIREMENT <br />• a <br />ti' YALUF <br />Cc'•P <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />..... <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 CERTIFY UNDER PENALTY OF LAW THAT I NAVE PERSO <br />AM FAMIUM WITH THE INFORMATION SUBM <br />TTED H NALLY ExAMINED MD <br />EREI <br />B TELEPHONE DATE <br /> I <br />N; MD <br />ASED ON <br />MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY flESPONSIBLE FOR <br /> OBTNNING THE INF01U1ATION, I BFLIEVE THE SUBMITTED INFORMATION IS <br /> TRUE, ACCUIUITE MD COMPLETE. I AM AWME THAT THERE ME ~ , <br /> SIGNIFICMT PENALTES FOR SUBMITTNO FALSE INFORMATION <br />INCLUDING L <br /> , <br />THE POSSIBILITY OF HME MD <br />MPR ~ ~'~ <br /> I <br />ISONMENT. SEE to U.S.C. ! 1001 MD ]] <br />610NATURE OF i v <br /> U.s.C. ! t31e. IH,rWeYa ,u,O~r rArM myna .rr.Y NcAW r.wa ,q ro J/0,000 Rll CIPAL EXECUTNE AREA <br />TYPED OR PRINTED <br />__-.-._-.__ .-._ _.._. --.-_._.. __ ..... ... _. .nsnmuNN.n irwr>o++lA+eWNmwn smmm.W SYr•:1 <br />._. _-._ ._ OFFICER OR A HORI2ED AGENT <br />CODE NUMBER EAR MO DAV <br />wmmo.,~nnv cnr~nnn nvn yr nnr Ywcn nvna lnereTence elr snscnmenrs pe/e/ <br /> <br />EPA Form 3320-1 IOB-951 Previous editions may bs used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) C U n ~! r. / ~ 7 7 n .+ ? -151 ' PAGE . OF <br />1 <br />