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<br /> <br />I <br />PERMITTEE NAME/ADDRESS p~iia~Wry NaNluulm IjOl~.raN/ <br />NAME ~ ,. _ <br />. ~, ~. e. .. - . <br />ADDRESS ~ ') .:..- -. I r . ~ ' <br />1 :,' <br />FACnm <br />LOGTION <br />NATIONAL POLLUTMT DISCMMOE EUMINATOM SYSTfM I/rY/cSr Form Approve ~• <br />DISCHARGE MONITORING REPORT /OMR/ OMB No. 2040-0004 <br />I-I6 17-IS) -. ,~ ~ - - <br />~ ' 1- A~~'dvel expires 05-31-98 <br />- ~ ~ P~FtMIY NUMBER OISCNXROE NLMIBEX (f ~ ~ ~ ~ " ~ + -. ~ <br />-~ <br />i ' MONITORING PERIOD ~ . , <br />YEAR MO DAY YEAR MO DAY <br />FROM I , ~ .. I TO -, - .. ~ ...: .. _ `- 11 <br />vo-71/ ru-za( v4.7s( ns•~7/ rzezsi /aa3f ~ NOTE: Rid Inr6uctl4`r MYoro~compbtinp thW form. <br />PARAMETER !3 prd only! OUANTRY OR LOADING /1 GN Onhl QUANTITY OR CONCENTRATION NO, mEDDENCY SAMPLE <br /> f46-53/ 150-87 1385 11653 64-61 <br />EX OF <br />TYPE <br />l32-37~ MALVSS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rt:-e.T) /Bq.BBI rB&7o~ <br /> SAMPLE <br /> <br />'''- °~~~ <br />MEASUREMENT ~ <br />~"~ <br />. , ., , • <br />., i., - PERMIT <br />.i-` .,o <br />, ` <br />`x~`'.k1 f!? <br />. i <br />.~,%:.i ~.o',me . <br />Y;T ~: ?~S'.>4: <br />:.^''Y :ef~ <br />~" -x 1 <br />P Z,'! a. <br /> REQUIREMENT . ~ . <br />r'. 'tip C r ~ r <br /> SAMPLE <br />• MEASUREMENT _ <br /> <br />PERMIT _ <br /> REQUIREMENT - ~ ~ ~ ~ ~ ~ <br />~ ~ ~ <br />-_~_ - <br />~~~ <br /> SAMPLE \ <br /> MEASUREMENT I <br />/ ~_ ~ ll ~/ <br /> PERMIT .. ~ ~ ... <br /> .REOUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> :REQUIREMENT ~ ~ ~ ~ ~ ~~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~~ ~ ~ ~~ <br /> REOUIREMENT ~ ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br />. PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT. <br />NAME/T1TLE PRINCIPAL EXECUTNE OFFICER I CERTI <br />) <br />FA FY UNDFA PENALTY Of UW THAT 1 HAVE PERBONAILY ExAMINEO MD <br />UM NATM THE INFDRMATION SVBMITTED HEREIN: MD BASED ON TELEPHONE DATE <br />`` ~ <br />' IJe I7 <br />r/^ J <br />(' A <br />A <br />MI <br />MY INOMRY Of THOSE INOIVIDUN.S IMMEDIATELY RESPON9BLE FOR <br />I BEVEVE THE SUBMITTED INFORMATION 15~ <br />OBTNNINO THE INFORMATON <br />`~ ` / <br />- <br />1 <br />I ( , <br />TRUE, ACCURATE MD COMRETF. I AM AWME THAT THEpE .AXE j ~ <br />i ~~ <br />~ SIGNIFICANT PEMALTIEB FOR SuBM1TTIN0 FN.SE INFORMATON, INCL <br /> <br />~ I] (, N <br />Y I; ~' <br />THE POSSIBILITY OF RNE MD IMPINSONMENT. SEE IB V.S.C. 1 1001 MD 77 <br />gIGNATURE OF PIIINCIPAL EXECUTIVE <br />/ 7~ 7- ~/. _ <br />~ <br />~ <br />. V.S.C. f 1310. (RrWtlrr uMr der mnmr nrY McAiW ~~ ~ ro S10,000 AREA <br />TYPED OR PRINTED wnmvnu*:vw/FanwxW Nn.rwn anwrelFW 6Y~l OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION Of ANY VIOLATIONS /Reference el! attachments oars! <br />EPA Form`3320-7~ (08-SBI PreWous editions may tie used. ~ r IREPLACES•EPA FORM Td0 WHICH MAY NOT BE USED.) - • (r -~ PAGE OF <br />