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ERMNI'EE NAMEJADDRESS (include Facilrry Name/LOCarion ifDif(erenQ
<br />NAME
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<br />ADDRESS ~ .
<br />hGh'1H THC~!FSCN CFl;EX CIhES
<br />L76H CC'kA5° CF1Y~', SUITE 101
<br />NATIDNAL POLLUTANT DISOHARGE ELIMINATION.$,YBTEM MPDESJ
<br />DISCHARGE MONITOgING REPO " DM?;e) v
<br />1PCF
<br />PERMIT NUMBER ' f ISCHMGE NUMBER f- F 1 1! I
<br />Form Approved. +
<br />1TMBNO. 2040-0004 _ '
<br />III IIIIIIIIIIIIIIII 41'[tx
<br />FACILITY GNA`.C JI)hCT ICA CC tl`_G(. ~ MONITORING ERIOD GCS. E CC7 CCCE IIEL C:CEtC
<br />LOCATION YEA MO DAY YEAR MO DAY _
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<br />CAhsCNDALE CU tlt.~? FROM q. ~ L7 Q TO 'sS LS 9~' t+0i?
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<br /> QUANTITY OR LOADI
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<br />(a Card Ony) QUANTITY OR CONCEN NO. FREOUENC SAMPLE
<br />PARAMETER 63
<br />3
<br />(54-6T) (3H-46) (48-53) ~ (5<-67) EX OF TYPE
<br />(327} AVERAGE MAXIMUM
<br />S-
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />IeaaTl avuYSrS
<br />(6a-68
<br />6&70
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<br /> MEASUREMENT •
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<br />,i lI ~ k E h C E C MEASUREMENT
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<br />i. FFLUEhT Gk055 YA LE ~I~UIREt~l1T .--~y~i, ` ;xyy ~+'- r t `F ~~' ~~ "~
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERS ONALLY EXAMINED AND TELEPHONE DATE
<br /> AM FAMILIAR WITH THE INFORM ATION SUBMITTED HER EIN: ANO BASED ON MY - /
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<br />AGyl
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<br />INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION
<br />1 BELIEV
<br />S IMMEDIATELY RESPON
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<br />SIBLE FOR OBTAINING
<br />FORMATION IS TRUE, ~
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<br />~~Y~~f~ , M AWARE THAT TH ERE ARE BIGNIFICAPfT
<br /> ACCURATE AND COMPLETE. 1 A
<br /> PENAL7IES FOfl SUBMTTN G FALSE INFORMATION, INCLUDING THE ~ -+A5-~
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<br />~I. C3S I J `yJ POSSIBILITY OF FINE AND IMPR ISONMENT. BEE 1a U.S.C. § 1001 AND 93 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE ~U
<br />Li• 7
<br /> § 1318. (PeneRiac untler Urese smiutw mey Inciutle rinw op m E10,000 arM a OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />TYPED OR PRINTED mevmum ~mpnsonmenr oroeMeen6monfhs entl SymrsJ
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />1(irt11TTE~ ':UST hCiIFY +[Ci 3C UA($ PRIGE TC CC~EIEIbG GISCLPhGt`.-FAhT 1.P..~, FG IY• EChTEIY °AlCIIhG FCh
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<br />UCG4B/SSC71:-11C5 1
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