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PERMffTEE NAMEJADDRESS prelude Faeiliry Name/Loca(ion if Diffe,rnQ
<br />NAME ~v, ., nn.,. '_'"
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<br />FACILITY
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (BMR;
<br />rz-+el (n- 4)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~' '" ~ L i0 .r ~'
<br />(zo-zfl (22-23) (1+Y5) R&z]I (2B-787 (30.31)
<br />Form Approved.
<br />. , , n OMB No. 2040-0004
<br />Approval expires 05-31-98
<br />NOTE: Read InsVuctions bef com leting this form. ;(
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<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 48-53 54-87 3845 4553 50-51 EX OF TYPE
<br />(3z-3n AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNRS
<br />fBta31 ANALYSIS
<br />(ea-58
<br />6&70
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<br /> MEASUREMENT
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<br /> SAMPLE ~~:':r GoaF.rr !`b AA~2 ( ? ?)
<br /> MEASUREMENT
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<br /> MEASUREMENT
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<br /> MEASUREMENT
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<br />MEASUREMENT
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<br />PERMIT rep ,n I N' - • - : A1tT;!`J1-`•]~ ?,
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<br />.•~: ELI }:Y" :: I'~ ~:, 74I-^- REQUIREMENT ~~"- Te"-r "~( 'Ff +~~~ ,~''
<br />NAME/1lTLE PRINCIPAL Fl(ECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM IAW THAT I HAVE PERSONALLY E]UMINED AND ~ TELEPHONE .
<br />ATION SUBMITTED HEREIN; AND BASED ON MV ~ DATE
<br />INDDIRY OF THOSE INDIVIDUAL
<br />FlchnrrJ (!'ills THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMnTED INFORMATION IS TRUE,
<br />,.
<br />_ (~ g ACCURATE AND COMPLETE.
<br />nVlronrTental . ana er PENALTIES FOR SUBMITPN ~
<br />I AM AWARE THAT THERE ARE SIGNIFlCAM )]O-S7O-272
<br />G FALBE INFORMATION, INCLUDING THE ~O ~ 99
<br />1111 /
<br />POSSIBILffY OF FINE AND IMPR ISONMENT. SEE IB U.S.C.4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED 4 1318. (P4reNm urMer Mass
<br />maximum lmpnsonment ol6aMwa slerufB9 may Include MIld9 up b f10,000 and W
<br />nBmonMS end5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS prererence an atracnmenrs Here)
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<br />EPA Form 33767 (OS~S) Previous editions may not be used. (REPLACES EPA FORM~T-40 WHICH MAY NO7 BE USED.) ~ ~ ., ~ r; /OTC !I 1 ~-T S?'t PAGE ~ OF
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