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<br />ERMITTEE NAME/ADDRESS pnclode Fanhry Name/Locaunn +f Di$eren0
<br />:AME r-~1 r:~Yr'. rnal rru~~rv r o
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DIMR;aI ~ r ° ~ n
<br />Form Approved.
<br />OMB No. 2040-0004
<br />'DDRESSCpL0aY0 ritNE ---- crfRBa~.Tf,t nf.n a ~PP~V.a~o.N~~~~~~-~~-~
<br />(SU9R Nk)
<br />S79i STRTE HIGR>wAY 13 ~:<-. _:.~`PERMITNUMBER DISCHARGE NUMBER F ~ PINAL t40F
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<br />NOTE: Read Instructions Defor : co, plating this form.
<br /> !3 Card Onty) QUANTITY OR LOADING'. ~(a Card Ony) QUANTITY OR CONCENTRATION NOs~ FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-61) ~ ~ l3B-45) (46-53J (5a-67) ~~EX of TYPE
<br />(32-37)
<br />AVERAGE
<br />"MAX.IMUM
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<br />UNITS
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS . ~
<br />~(ez~I ANALYSIS
<br />(sa-69)
<br />(69-70)
<br />!' c SAMPLE C•F CcOOV~', ':~414P.i1 sti=tr!.k .: ( l.Z) -
<br /> MEASUREMENT ^";y{~1.`'
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<br />SIi:;P6NUYP MEASUREMENT `°~" ~
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<br /> MEASUREMENT
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<br />(A $ F E) MEASUREMENT
<br />U 1 U A 5 1 U U 1- PERMIT !!~^~91MH ~!lC~t - t 4:,` r• # ~ , . d '
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<br /> MEASUREMENT '
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<br />TRRU TN E'P.TMeNT PLA N7 MEASUREMENT
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<br />L' 1 5S 0 L Y; D MEASUREMENT ~.
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<br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSONALLY EXAMINED ANO
<br />ATION SUBMITTED HEREIN
<br />AND BASED ON MY `
<br />~ ' TELEPHON E ~ DATE
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<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING ~
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<br /> THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE, ~
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<br />ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT
<br />PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING THE ~
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<br />POSSIBIL7TV OF FINE AND IMPRISONMENT. SEE 18 U.S.C. § 1001 AND 33 U.S.C.
<br />SIGNATURE OF PRINCIPAL E%ECl1TIVE /~
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<br />TYPED OR PRINTED 4 1319 (PenelUes untlar mesa steWes may include lines up (o E10.000 end or
<br />maximum impnsonmenr of beMSen6monlhs end5yeers.) OFFICER OR AUTHORRED AGENT
<br />A p
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />VVMMhNIJ ANU tRHIANAIIVN Uh ANY VIULAIIUNS (ReierBrlCe B/78deChmenlS herB) '
<br />SEL'TLE:iULt SOLIDS LICIT Af~FLIP:.5 USLY IF <=IOYR,?aHF ?RECIP (:11811' IS CLAIdSFD° ?F CLAItf APPRfJYED AY yGCI:,
<br />T$5 G IRON LI!!ITS NILL NOT' '+E APFLIFD Tn 9F PORTED !!E'ASURS)!Bili?~",:^ SFE I. A. 2, F1:. 5 POA BURDCM OF. PROOF
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<br />EPA Form 3320.1 (OSc95) Previous edltiona may not De used _ ~ (REPLACES EPA FORM T 40 WHICH MAY ND~ ,~ v~ T / UU D 4 ,fp, • • ;may ,PAGE, . ~ ~OF.
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