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PERMIITEE NAME/ADDRESS pM,drfrNlry9mw'facaam dDlQ.w1 <br />NAME •'( •,T ~ . . <br />ADDRESS ~ ~ `• ~ r - ~ - ~ ~ ! <br />r:vCLt ~ :, C <br />FACILITY <br />LOCATION <br />..' ~`FIS Y. '~ .. _ <br />NATIONAL POLLUTMT DISCHMOE ELIMINATION SYSTEM INPDESI FOFm ApprOVed. <br />..., ,- DISCHARGE MONITORING REPORT lOMRI - OMB. No~2040-0004 <br />11-161 17-191 ' <br />q r r - ~ ! ; - ~ ~ - ~ ! Approval expires OS-31-98 <br />PERMIT NUMBER DIBCXMGE NUMBER - <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY ~ <br />FROM - TO -: .. _ .,... _ I .... , <br />' ~ ~ 126111 122-131 114751 /16771 119-191 !36311 NOT'e: Rasd Imtruetiom betor completing this form, <br />PARAMETER l3 Grd Only) QUANTITY OR LOADING !I Grd OnIYI GUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE <br /> (06531 !545/1 /38-15 /46531 !546/1 OF <br />/37-371 EX MALres TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS leas/ 151-581 159-701 <br />' SAMPLE ~ " ... .. / I -~ <br /> MEASUREMENT <br />.'I:i - ' PERMIT ... •:~?:: ,;e .... .. .. .. - ~ 1 <br />Y ' <br />- t : ".' i ~ ~ -~ 1 V ' 1 •! : REQUIREMENT r . <br />„ _..^;! '. t I. SAMPLE .^. :1 r: ':^:.^:;:;: ~- ( ~~ <br />. -~ MEASUREMENT <br /> <br />~`J'. trl PERMIT .. ~ `:r 't ,.-: e~: f: '<t: ;.•;..:.+: - -,c+~ :~r rn.,- i .V. i• <br />^ <br />/ •~.,, <br /> <br />- <br />.. Cr:~ .. '~ . REQUIREMENT ~ -, .., :..- <br />L <br />~2 <br />y ,•Y <br />/, <br />~ i <br />. <br />r <br />. <br />~ <br /> l / <br />~ ~ l U . t ~ - SAMPLE .. .. ~ 1 <br />.I , - ! ~, _ MEASUREMENT <br />'J ,. ~ PERMIT ~: t: ^_:~ .-.;: 's ~: e:': ~ 1~ - -! <br />7^ -,.. <br />_.C .;P•-... r REQUIREMENT ~n ~. ~ 1 ~ _ /! _ <br />,+_ <br />_1,:._'~:-•, .i '.TT1. SAMPLE C: r: ~` ^n-n+: ~: ~ ~ ~ <br /> MEASUREMENT <br />~, ~:~:~ rl J ~ PERMIT ,:Yh P+`. li .. ..~ C^: .~ r ~ r ~ /~:'.. r,..~_ ~... ..'r, / <br />•-, , + ., +• r q r r : ~ REQUIREMENT •; E; ~ ..., .. . <br />~~i; ~. :. :~:i~ ~ETTL r.- _ - SAMPLE .. :G:?': .. :...... - .~ <br /> MEASUREMENT <br />•. ~ I 1 f ~ .PERMIT . ': q: r {- is r ~:::: I:... .. .. 7 : ',"` •: " . ". ''" . ~ / <br />.~ <br />t ~- ..' I : ~ ^'; - 'i A ~ ~ REQUIREMENT ~ i r• - r , t~ , n q - r_ y ! I , <br />s1 .,. .,. . SAMPLE ..:. u:•{:.: ..:,•. r; !r' ... ~ 1 , -1 <br />. ='/ . , - - ~~ '"'= MEASUREMENT <br />i;l ._ •i l T ~ PERMIT" .'tr ^, rr r. .sr: ,. ct •, r:: ^~r...... ..., -, , <br />~ ~ ^ - <br />- ~ 1 E ~' •' - ~- ~7 : - ? :~ ' REQUIREMENT T • '~ / <br />• ~• SAMPLE r..:' c ~; .. .. ! • I <br />(:~ ~ ~ :i MEASUREMENT <br /> <br />lyf t:) r• ,~ <br />I ~ PERMIT ;oi ,-. r•~ 1G r• rt :;t it•.. ~.h.I. ~ '[['., <br />I ..i.+ <br />/ <br />,• <br />- .. COA <br />- -' REQUIREMENT ~ to •, r,. t, ..l. -t, <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF lAW THAT I HAVE PERBONALLY E%AMINED MD <br />MIUM WITH THE INFORMATION SUBMITTED HEREIN <br />MD BASED TELEPHONE DATE <br /> ; <br />ON <br />MY INQUIRY OF THOSE IMDINDUALB IMMEDIATELY RESPON9BLE FOR <br />t~ t <br />RICi1GYC <br />1II~~ IEVE T~B <br />~ <br />N <br />~ <br />A <br />E <br />U <br />wMl <br />TO <br />i RUE. <br />A CUMTE <br />AXD <br />COMPLETE. <br />THA <br />I <br />1 <br />RE <br />THERE ME <br />{ <br />• <br />- <br />n <br />' sIOMIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING / <br /> <br />L <br />•.,E:r <br />.al^ <br />a <br />!F <br />Enviroi:r,9` , <br />THE POSSIBILITY OF RNE MDIMPRIBONMENT <br />SEE IB U <br />B <br />C <br />11001 MD93 <br />n70 <br />br :-~iJ <br />'] <br />' <br />~ <br />[~ 7~ <br /> . <br />. <br />. <br />. <br />U <br />S <br />C <br />E tats <br />6MWU•. uMr erg mvn•• rNr <br />dr fv <br />M:cA <br />ro lIO <br />OpD <br />BIONATURE OF PIIINCIPAL E%ECUTIVE . . <br />, <br />TYPED OR PRINTED . <br />. <br />. <br />. <br />r <br />r <br />, <br />wr w <br />r:d w,nr•h:vn irwism:vtW MrwA•n a marNa rW a EArral OFFlCER OR AUTHOR12ED AOEM AREA <br />CODE NUMBER YEAR MO DAY <br />l•VmmO~IJ qnu cnrlnnnrrvn yr nnr •rv~n, w,... rnsrerenw en srucnmemr nrra/ <br />I .J' ^, _ .. r _... n ,I _' ~... f E <br />EPA Form 3320-1 108-951 Previous edlUOns may be used. (REPLACES EPA FORM T~LO WHICH MAY NOT BE USED.) . , „ „, .. ~ PAGE • OF <br />_1 r` <br />