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pERMITTEE NAME/ADDRESS p+dwh irwryNs/l,er.na. dolfi..•0 <br />NAME 1' 1.. - ~ . ~ _ ...~ ~. ~ , <br />ADORE55 ~ I ~ - i . ~!' ~ -. '1 , - ~ "' 1 •: <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTMT DISCHMOE ELIMINATION SYSTEM INPDESI Form Approved. <br />DISCHARGE MONITORING REPORT (OMRI .. , . ~ . .. . ~OMB~.No:,2040-0004- ~ <br />17-161 117-191 <br />_ ~ , , .~ . ., Approval. expires OS-31-98 <br />PERMIT NUMBER DISCHMOE NUMBER ~ '• • ` <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM •~ ~ .~ TO ~ .. .,. - -. _ I .,_ I .~:. <br />11x111 IJ1-231 174-251 n6771 178-291 136311 NOTE: Raed iNtnlCflpu bstora tOmplstinp this form. <br />PARAMETER !3 Grd On/yl QUANTITY OR LOADING !1 Grd Ontyl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> ldb531 !5661 I3BJ51 lab-531 15a-611 EX <br />l31-371 MµYAS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rst-ssl !sd-cgl 169-701 <br />i ~~. .. r J.'.. ,. SAMPLE ~ :: t,:^^.: r-:: ... .. ... ~ ( "11 <br />~~. ~. •~~•~ MEASUREMENT <br />i'~r-'4r f; ~+ PERMIT 't ~, ~t« s, r..; ,r. .v r. Z r ." '/ +f.. <br />. ;, ~ - ~ r - .REQUIREMENT ~ .. Z ~' !. ", <br />l''- <br />. T I b ~.T - <br />I . r u <br />L l': • I f ~ . ' i i; I : a SAMPLE ~ '1 : { ..:. <br />~ '- * ~ F..'' <br />•{ MEASUREMENT <br />- <br />tU ~.'.~ ~ '• f PERMIT y•. r1 ~u'{ 1fiT. ~; :., .. r. r; .. •a: y..~. :; .. .y rc ::.zi r. r+ <br />., i ; 7 q { - REQUIREMENT ? 11 : n ~' ~ ~ I L Y w s •_ n ~ .. <br />i?: \'i `1 ,:,1_I SAMPLE ., :r:~ r ta) .. .. .~. .... <br />11 -•+L MEASUREMENT <br />.I~-, ., 1 0 PERMIT ::fG h.»h 7 Y - nt ,•t tF ':.- (e ..;,{. .. .~. y .rat <br />~i ~~L~1 f. '.i l'. P.~SS T'1 REQUIREMENT ~ Ie:ri •:~r .,. <br /> SAMPLE <br /> MEASUREMENT <br /> .. PERMIT <br /> ~fiEQUIREMENT <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 />NAME/TITI.E PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDE11 PENµTY OF l AW THAT I HAVE PERSONALLY E%AMINED MD TELEPHONE DATE <br /> AM FA MILIM WITH THE INFO RMATION SUBMITTED HEREIN; MD BASED ON <br />tlll <br />I <br />h <br />i ~ R <br />DIIA <br />E <br />N <br />I~ <br />. <br />i <br />e <br />aeE OBTNNNG <br />THE NFORMATION <br />BE EVE THE <br />SUBMITTED INFORMATIO <br />S <br />r-, r p <br />_.l V~l"OTII'IQ ~f7~ ,' IJa'rY°r TRUE. ACCUMTE MD COMRETE. I AM AWME THAT THERE ME <br />SIGNIFICANT PENµTIES FOR SUBMITTING FµSE INFORMATION <br />INCLUDING <br />O <br />~~ 57G-27:,3 <br />T? <br />7a <br />ag <br />' , <br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE to U.S.C. f 1001 MD ]] <br />' gIONATURE OF PRINCIPAL EXECUTNE , V <br /> U.S.C. E 1 ]10. lgrWb• ulWr ewFr Aerem• nvr i.cMd~ rYeF HD ro t IO,ONi AREA <br />TYPED OR PRINTED Wnmuim.n inA'/o•nrrf arMnrwnsma•rNa endb F~a! OFFICER OR AUTNORRED ADENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRefsrenes e// sttechmente hers/ - <br />r F <br />r F <br />_ r <br />EPA form 3320-1 108-951 Pravlous sdlGOne may be used. IREPLACE6 EPA FORM TAO WHICH MAY NOT BE USED.) y ~ „ .,1 _ .- _ , .. PAGE , OF <br />