|
Jd,...:.TfE :.....Nii,'...::.1/t55 i•'.v~:~won~ ued,m I/O,~i.wq
<br />NAME ._ ^ ,.
<br />ADDRESS - -
<br />FACILfIV "
<br />n ~. ~ ~ ,
<br />LocAnoN '
<br />~ .
<br />NATIONAL POLLUTANT DISCNAi1DE [uMiNAi0n ai ~~2.. i :: ~'__, FOnn pppl.: ~~~•
<br />DISCHARGE MONITORING REPORT lOMRI ., r - r : ,^ ~ ...^ = ~ 0 6 Na: 2U4u-0w,
<br />!T-!el //7-191 .., r. a, 0.Q.
<br />Approval expires OS37.98
<br />_-~~1PERMIT NUMBER DISCHARGE NUMBER ( _ I. ~ ! '-' 1' ~ ,
<br />MONRORING PERIOD
<br />YEAR MO DAY YEAR MO DAY __.
<br />FROM ,: I .., TO !~ >. .., : _i.. .. i__~ ~::
<br />naz11 rzaz3l rzaz5r rzszn rz3-z91 f3asrl NOTE: Reed IneWetlorr Gfore eomDleTlnQ Ehi form.
<br />PARAMETER !3 Gre Onlyl QUANTITY OR LOADING !~ Grd Ontyl QUANTITY OR CONCENTRATION NO• FREDUENCY SAM
<br />!JI
<br />371 lIB53/ !51-61 !38451 lIE631 l5F61 OF
<br />. EX NALY9S TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !et-e]1 A
<br />16~-681 169.701
<br /> SAMPLE .. ,.:...:.. .... ~ ... ., . .. ,.: ..:. , ( - ~ t
<br /> MEASUREMENT
<br />~:/. ~ ~ .. ~ PERMIT ;: y;;: .... .i z::;< ~ r~ ~ . ~ :I. c ... •, ~
<br />y ~ ` ..:. (.! ."
<br />` '
<br />~ REQUIREMENT ~
<br />r ,
<br />~, ,• ~ ,
<br />Y: Y v8'tj .
<br />L ~ r ; i. SAMPLE ..
<br />~~~~ -~ .: .`-'1 :
<br />~~~, : r: r::~ . ~. ( i i ~
<br />..
<br />1' MEASUREMENT
<br />, ~
<br />~ AEAMIT +;t:fifi" , ioYS{rvII' G:: :; :Y :t,: r ,
<br />- REQUIREMENT ..
<br />~ ~ ~ 1
<br />~ . . ~? yc •::~ l ^i `... r .} A r M - / " %
<br />"..I!.~:;F :.°L ~. L"~ SAMPLE .... •. ~ ( or)
<br /> MEASUREMENT ~ ~ ~ ,
<br />I
<br />~ .AJc.!
<br />-.'. 1 0 I. PERMIT .. •. .. ... _ ... .a~: r... r.r,"0.I ~?. / ';~°~ :~?u
<br />. REQUIREMENT ~
<br />~ L
<br />," - i ,~
<br />t.• r
<br />
<br />~
<br />~asr!N
<br />L ~ i
<br />l'L 4 L SAMPLE , r: r ... ... (
<br />~ : }
<br />.
<br />E MEASUREMENT
<br />(4,: fF.)
<br />_ i (. ~ PERMIT q~:}•r ;•; •:sX. .9 s; a.:: ::::' ., .: 7~ 7.
<br />~~. ; I,i ..
<br />. ~: /
<br />::~ ~ ,.
<br /> REQUIREMENT ~
<br />
<br />i .. 3 ~ I' (~.:{ i•, :, `.. SAMPLE ~; ~ ~,~..+ :: ~ .. ( .I ~
<br /> MEASUREMENT
<br />.i . ~ 1 l ~ ~ PERMIT ,;::;x,^-.+,: •;: ~. :F {: :: :(: t,
<br />~ .:: ~ ~ .. .. ... ~ f1 ~ '(7 .~...; ',' i., ;,
<br /> REQUIREMENT ~
<br />I • ,[ ~ , 1 , r , ., ~ ,.
<br />..~.
<br />/;
<br />~.
<br />i 1 ,: L!'. ~, .. ... „
<br />• r SAMPLE ( .~~)1
<br />.~~ .. ~..~ ::. .. ~., ..
<br />~:~ : ~ ~ .:: :;
<br /> MEASUREMENT
<br />.
<br />r PERMIT ., t'L :s.-i
<br />~ 4;;?;)f; "' ;R ,•:.yM ,.. '.tt re' p '.I;,
<br />- .., REQUIREMENT ~. ,~.
<br />Y
<br />'~
<br /> ~;
<br />;
<br />a
<br />: ~. I :$
<br />~. L ~~ ~ ~ SAMPLE .. ~ .. .. .. ~ ( t I t
<br /> MEASUREMENT
<br />i /L,.
<br />7 , _ 5
<br />~ PERMIT . , t: i' ..•'rs':.. .. ... .. . . ., {'{'
<br />^ •I', * ~ } , .. ?. i ... " -'
<br />L' ; i.. V
<br />r' REQUIREMENT - ....
<br />w
<br />4 .(. Y
<br />~~ . l ~ . / ~
<br /> ~ ,
<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFlCER 1 CERTI
<br />AM FA FY UNDER PENALTY OF L
<br />MIDAR WITH THE INFOR AW THAT I NAVE PERSONALLY ExAMINED AND
<br />MATION SUBMITTED
<br />ERDN
<br />N
<br />9
<br />E TELEPHONE DATE
<br />
<br />i •
<br />~ I ~ ~ ~ I(
<br />~ ~^ ; A
<br />H
<br />D
<br />AS
<br />p ON
<br />MY INQUIRY OF THOSE WDINOUALS IMMEDIATELY RESPONSIBLE FOR
<br />GRINNING THE INFORMATON
<br />I BELIEVE THE SUBMITTED
<br />NFORM
<br />I
<br />T
<br />
<br />/
<br />, I
<br />1. I
<br />~ ,
<br />I
<br />A
<br />ON
<br />S
<br />TIIUE. ACCUMTE AND COMPLETE. I AM AWARE TXAT THERE ARE ,
<br />
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING ~.
<br />
<br />C I) . 1 , ,
<br />THE POSSIBILITY OF flNE ANO IMPPoSONMEMT. SEE le U.S.C. 1 1001 AND ]]
<br />Il/J
<br />' ~ 7--~-//
<br />• _
<br />~~
<br />/f
<br />~ (
<br />~
<br />i U
<br />S
<br />C
<br />L 1]te
<br />lM,rlWr
<br />+sr r/
<br />mn
<br />N
<br />Ad
<br />~
<br />SI
<br />PO SIONAl11RE OF MIINCIPAL EXECUTIVE ,
<br />- T ,
<br />TYPEDORPRINTED .
<br />.
<br />.
<br />.
<br />u
<br />ww
<br />mr m.y ,
<br />c
<br />r
<br />mrf w ro
<br />O,
<br />O
<br />I
<br />i
<br />'
<br /> o.
<br />nmu
<br />nun inpn
<br />gvnPntMberrwl6mmNS wvd6yAVal OFFlCER OR AUTNORRED AGENT CODE NUMBER YEAR MO DAY
<br />..vnn.., .y. _.~ ; J ,.. ~ ............... ..... .....r.. ~......:,.e,o,.,...o o., o..e...:.( =.., •.V er ' ~ - . , . - . ' ~ ~ . : ' c i. ., ~ ...
<br />,
<br />E ~
<br />Epp P'orrtl 20+1 ~ OB-951 PraVidue editions may ~ ubdd. ~ ' - (REPlACE6 EPA FORM T~0 WHICH MAY'NOT BE USED:1 _ - ~ PAGE ~ OF
<br />% 1 - - ~ I
<br />(
<br />L
<br />
|