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PERMITTEE NAME/ADDRESS llnrlude <br />Farilitp A'ame/L orarinrr if dif(erenll <br />NAME___~__ a <br />ADDRESS N.t~,A h LR HI'{F <br />- ----------- <br />_ - - rr - - _ _ - - - - - - - - <br />___-_-±~Ti --------- r~n~- <br />FACILITY <br />LOCATION _ <br />9PTN- .. 4 <br />NATIONAL POLLUTANT DISCHq RGE ELIMINATION SYSTEM (NFDE$ ) <br />DISCHARGE MONITORING REPORT ! DM1/R/ <br />11-!61 (I7 IVI <br /> C~'.~91005? OOl <br />A <br /> PERMIT NUMBER c <br />c wowecw <br /> MONITORING PERIOD <br /> YEAR MO DAT YEAR MO DAY <br />FROM ~ TO <br /> (?0-1IT (11-_'.i) !N-?3) C6-?]) (?3-?9) !?U-71) <br />^~ DITCR '"0 '7. FR.PUf:SA"'~ID9 <br />(S`:9R SE) Form Approved. l~~rl <br />F - FI'7A1. OMB NO. 2040-0004 <br />`! 7 H r1 R Approval expires 10-31.94 <br />NOTE: Read instructions before completing this form. <br /> (J Card On/}') QUANTITY OR LOADING (4 Carl Onl)'1 QUALITY OR CONCENTRATION <br />PARAMETER (46-5JJ (34-b1) (?S-0S1 (46-5-7J (SJ-6l) NO. <br />EX FREOOUF NCV SAMPLE <br />TYPE <br />(??-J71 ANALY95 <br /> AVERAGE MA %IMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> l6 rt•)I (6ab3) 169-00) <br />)IL AYD !4RIS~ , .' <br />.e~„' <br />J:' <br />- Q~l w <br />~$'vt## ;: :: <br />r•' <br />~ _ <br />~ <br />' <br />• SAMPLE a <br />, <br />. <br />. ( <br />) ,. .•• <br />. <br />- r <br />vr. <br />v <br />9I50 AL MEASUREMENT <br />3'{r' 6- 1 PERMIT ~'~'~"? <br />,-r "~ ~R~PClRP" E5=1 ~ r,`x: '';!ir##0r;>7i ~#~#4: .. EF <br />tLT 7SUiT <br /> <br />ScFuUEYT ~RJ5S YALU <br />REQUIREMENT , <br />.THS.III y~lt <br />'jc! P <br />NO=D <br />`r'!' , . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br />V~ ~ - <br />~t <br />~'' <br /> REQUIREMENT i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT 1 .1;.y;''~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ... _ v <br />t , r <br /> REQUIREMENT { <br />6CTy, <br />; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT .~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cERnFY uIJOER PENALTY OF Lqw THAT I HAVE PERSONquY E%AMwEO TELEPHONE DAT E <br /> AND AM FAMILIAR WITH THE INFORMPTION SUBMITTED HEREIN: AND BASED <br /> <br />L ON MY INQUIRY OF THOSE INDIVIDUALS IMMEOIgTELY RESPONSIBLE FOR <br />_ ,t~f r~ OBTgINING THE INFORMATION I BELIEVE THE SUBMITTED MFORMATION IS C\a <br /> TRUE AfCURATE AND COMPLETE. I qM AWARE THAT THERE ARE <br />SIGNIFICANT PENALTES FOR SUBMTfING FALSE INFORMgTIQN INCLUDING \`IYr <br /> <br />r'` <br />( <br />THE ROSSIBIUiY OF FINE AND rMPR15oNMENT sEE 1e use 4 loo/ AND ~~11 <br />~ <br />00 <br />0 ~4 <br />, w.t <br />L r <br />33 u5C 4 1319 <br />l4 <br />ln <br />d <br />rh <br />smmres ma <br />l <br />d <br />li SI ATURE F PRINCIPAL E%EC TIVE L 4~- ~ ~ ( ` <br /> <br />TY D OR PRINTED ( <br />na <br />rs un <br />er <br />ea <br />} 1 r <br />u <br />r <br />on up m <br />flOpRl and nr maumum imOrisonmrnr n! brru rrn 6 monrh, anJaS yean) <br />FFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> CO <br />COMMENT AND E%PLANATION OF ANY VIOLATIONS (Relerrnce all arrarhmrnrs hrrr) <br />''TvI"OF 7DL4TILR ORGANIC TOYIHS ANNRALL~ PFTtiPEt7 "_1/1B E O4/lA, R°SDLTS DU' NO LATER TH~II 07/28 QITR -'+Jn <br />~T3. Dl1R-I.^.4, PP 10-11.' GRAB SAf7PLE ANAL7SI5 FOR OIL f; GREASE REQUIRED iF YISIBLB SHEEN IS O95ERVp~ - <br />EpII: Form -1-(Rev.9-~ eY evious edi Ions may 6e used'-' ( LACES PA M T- 0 W IC MAY NOT BE USED.I 00039/950 1tt3 PAGE 2oF <br />~..,r <br />