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PERMITTEE NAME/ADDRESS (/wrlib Fr•Wry Na./lamlm dD~~i.nu) <br />NAME AC;OL'JAYO CCAL CON.FAdi t L.6. <br />aoDRESSCULJ4Y0 PINE <br />5731 STATF, HIGHI+AY 13 <br />lIEEKEP. CU filb4l <br />FAauTY <br />LOCATION <br />1 ^^F^'~ti~e ~ - D w J C T 4{ Y T <br />NATIONAL POLLUTMT DISCHMOE ELIMINATON 9YSTEM (NPDES) <br />DISCHARGE MONITORING REPORT IOMR) <br />lZ-161 l17-I91 <br />/'nr_A4 A CAC <br />PERMIT~NUMBER DISCHMGE NUMBER <br />...SR~y®~. a.' ~. y <br />FROM <br />~K'~'~~ MONITORING PERIOD. <br />YEAR1iM0 DAY ~ YEAR MO DAY <br /> <br />SEC 16 PGND <br />(SU6A 6H) <br />F - FINAL <br />CIROA <br />Form Approved. <br />OI~AB N°.i wOE4NO-OOO~4p <br />Tv GOApprovel e><plrea OS=3158 <br />12345 <br />98 Cl Al -TQ.. 9A C3 ?1 ~Y~, Fr OLSCHAhE I,~Gm ~><;~Y: <br />n62rr rnaxr n~OA'rT':QGZ71 l18-291 !3637/ NOTE: Raad inetructiaru before o ~ktinQ thu lorm. <br />PARAMETER !3 Grd OnlYl QUANTRY OR LOADING. <br />~ml ~y7A~G~~r~d' OrilYl QUANTITY OR CONCENTRATION (JO. FlIEOUENCY SAMPLE <br /> ,, <br />!16531 !SC-e/1 ~-:Ul Q-~13B<51 ~ M6-53 15d-5/1 EX DF TYPE <br />I 132-37I <br />AVERAGE <br />MAXIMUM <br />UNITS <br />~NIININIUM,'~ <br />AVERAGE <br />MAXIMUM <br />UNITS <br />rs2-sal <br />15q-58)a <br />!5&701 <br />AIL AND GREASE SAMPLE Yr~l;,rsFg ( 9~ L~=rp~~ p;r7#rfi LYY~Y~u'+ <br />Y j 5 U A L MEASUREMENT <br />i4U66 1 (1 U PERMIT .^.:Y.'i}Y:Y< ::':«~-.~; <br />J.: : ES=1 ari>7.~;4'~F:!:':. .. ~3za.~s,t 4-'.>;::ra rt;.,; £EKLY 'ISUsi <br /> <br />PFLU6YT GAOSS YALUF REQUIREMENT . <br />7_NI::Tc: <br />f.7 .~'•.y::..~~ <br />~`s.::K3':~::::::: ~.~ . <br />,; •;=~•; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ <br />~ ....:.. <br />~ <br />~ <br />~ ,,, ... ..~::::.,.,v:,.Yg;;y: <br />~ ..~..... <br />.. . . <br /> . <br />REQUIREMENT .. .:.:~:' <br />: <br />,,,;:...;. ~:x:T*-+=<s,~'; <br />:. ~: . <br />. <br />::.. <br /> _. ..a. c:' ..... ::.... .. <br /> SAMPLE ' 3r.",-s:~~_ <br /> MEASUREMENT fii~'t <br /> PERMIT ~ ,:.: e: •.,i ~ .. <br /> REQUIREMENT ~ ~"':~~::.r <br /> <br /> <br />,:;:.:, <br />,. <br />'~ <br />y.... ~ <br />;.. <br />,: <br />,.... <br /> <br />.. . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ 's`::.'E `ri:: ,+.. .. :. .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ .. <br /> REQUIREMENT ~~ ~ . ~ ., <br /> SAMPLE ., <br /> MEASUREMENT <br /> PERMIT <br />.. <br />.. . <br /> REQUIREMENT .. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />;..:. <br />~ <br /> .REQI,IIREMENT ~ ~ ~~ ~ ~ ~ ~ ' ~~ <br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I cERn <br />AM FA Fr uNDEa PENALTY of <br />MILIM w1TH THE INFO Lww THAT I HAVE PERSONALLY ExAMI <br />RMATION SUBMITTED HEREIN <br />MO B NED MD <br />ASED ON TELEPHONE DATE <br /> ; <br />MY INQUIRY OF TNOSE INDIVIOUALa IMMEDIATELY gESPONaIB LE FOfl <br /> OETNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORM ATION la ' <br /> TgUE. ACCURATE AND COMPLETE. I AM AWME THAT THE <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />IN RE ME <br />CLUDING ' <br /> <br />~1r` ~ ~~~ ~ ~~ , <br />THE POSSIBRITY OF NNE MD IMPNSONMENT. SEE to U.S.C. 1 1001 AND 73 `' <br />~ ~ Y - ~ /rl <br />~~ <br />/~ <br /> ' ~ ro 510,000 <br />nm <br />I~M <br />~ ~ SIGNATURE OF PIIINCIPAL EXECUTNE AREA <br />TYPED OR PRINTED .ns <br />.+ <br />pbo+wwl <br />M wr monN.~ E.r..l OFFICER OR AUEHORIZED AGENT <br />CODE NUMBER YEAR MO DAV <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRerersncs sn s7rochmenGS here/ <br />SETTLEABLE SOLIDS LI!1IT APYLIfiS L)NLY ZF Cs 10-T A, ~34~,2tR PkfCIF f.YEtlt 1S CLAIBEC. IP CLAIlf AFPROYED 3Y <br />NQCD, TSS E IkON LIt1IT~ HILL NOT 8E APPLIED TD &EPCRTED "fEASUFePFtl7S--SFF. i.B.lA, PG 4 ArD I.B.1D, PG 6, <br />EPA Form 3320.1 108-95) Pravioue editions may be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE UbED.I PAGE OF <br />-- OU ~ 977kiLt-p911 2 <br />. ..- .. ...1.tr-- .....vs...... _ :, a.....r'~.M"~.'... _ ~ :f}r r ..-s+Y•':i~!a','6~2 _<.' <br />