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PERMITTEE NAME/ADDRESS (Include faci(rry NandLoca(inn ijOgeenq <br />NAME ~ v .. , . - . - _. . <br />ADDRESS,. ~:':.., 1 ~ ~ - _ ,. ...r _ ^ ....... ,. <br />FACIIJTY ' <br />LOCATION I <br />~.T ,- ,r T- -.-T v '-. r.-.-, it mur <br />NATONAL POLLUTANT DISCHARGE ELMINATION SVSiEM (NPDES) Form ApprOVed. <br />DISCHARGE MONITORING REPORT (OMR~ <br />T s OMB No. 2040-0004 <br /> tx 1sl l <br />n . ti , ^ A <br />l ex <br />ires OS31-9B <br /> pprova <br />p <br /> <br /> PERMIT NUMBER DISCHAFIGE NUMBER ., _ ^ r , , ~ , „ ,. ~, <br /> MONITORING PERIOD ~ ~~ ' ' ~ ~~ "" "~ ~~ °~ T ^ 'r. <br /> YEAR MO DAY YEAR MO DAY <br />FROM o'T n7 ~~ TO » ~q 7n _,. <br />~ ~ ~-~(. rt.,,. ~, I--) ._..:. <br />fxazll (x2-x~l (xr-xst (zaxn tzs-nl r~u.T,l NOTE: Read Instrucllons bef ore'camplettng this form. <br /> (3 Card Ony) QUANTITY OR LOADING (4 CeW Ony) GUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (4653 (54-6/ (3H15 (4E53 (54A7 EX OF { <br />w` PE <br /> LVSl9 yL <br />(~~~ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE ti MAXIMUM UNRS ( <br />!W6 7 <br /> <br />C l)vi ':C"i:',?'7 SAMPLE rt'...:r ^. `. :c Gt?'; t.`. ..F.. ,.:... ~ ~ ( ~r) ' ~ ~ <br /> <br />MEASUREMENT \~S/ <br />r <br />1 ) <br />Dtl l jl.. ! r, r, PERMIT*_ fA+i?Qt#,io9F ~1iyIaLR7#; «:t: ~t)tb:1{tJ%+9t 5-eL85 . ' • R~~{7T?+~: .:,~/ i-,,. .. <br />°FFLI;._' v1 ~[' "s r nF REQUIREMENT <br /> <br />.... : . ", ;: -:` ;. ~;Yth t, .. <br />~, ... <br />P y <br />r - .;. ..:- <br />F'1 SAMPLE Gr'aa 40 tt.^.zta ^ <br />- .:t'x n:t~~' Q <br />~ ( 1 7~ ~ ~ <br />~ <br />i <br /> <br />MEASUREMENT <br />+ <br />1 r <br />U I( t <br />J <br />7 1 <br />l <br />J0400 L .7 ^. i"y~yERMIT~ ~ ~ Si# _ 4+'C ~i1+ <br />T <br />` <br />` <br />,~ <br />. . <br />_. E' 4' L U E" T ~ ^ 7 ^ V L L T; Y pEOUIRi=MENT x. ., ,~~ "' ~ n': r: r g <br />' <br />lC iY'~ ~ Qrl ~~~._ <br />.: ii..i '15r '[!T\:. SAMPLE a.aa R(r tr^_taR.t ar..r.~a ( r7~ <br />_,IJ ~ ~~ c.; C' '. C~ MEASUREMENT ~ a ~~ ~ ~/7 ~~1 <br /> <br />LU'~ iU ~ D U <br />PEPM `'T <br />_~„ D14pRsx <br />##AM <br />4Rrc <br />'' ~AC$iOrA. <br />1R ~, $t* <br />RTDn~i` - <br />.. <br />?~~.~" ~- 't <br />r <br />al c T'I~•'+:ar i ?EL11+' REOUIREM _ <br />~ ' ,Y ;' .. +trORa in -h T r ~.-/r :' ^ <br />` <br />S'1LI~.i~ T7?4!. SAMPLE T :`::a^'a0 rrgaRa°T "`Y'^-"'•, t • r7) <br />S'; ~. ! • `: N r. ; '1 ~ MEASUREMENT r <br />( r1P. <br />LI II',3U L D D PERMIT MIA11~[,_ 0ta#910 GF`.' ~ ~~. a##~`#.r '~C Tn ~~~~`' C~'+~ <br />~'n <br />,' i. tJ is N T G R J i S P i "" REQUIREMENT r~Y y~!- D R _ 'i! ' • • r ~' ! T . <br />- <br />~')f.7?Sr SET*LP.0.Pi. `' SAMPLE -Tatra Qtr rr ~tSrC :t .': •t <br />~~ <br />a- <br />! ) `\ <br />III fl <br />~ f <br />~ <br />~ <br /> MEASUREMENT ~~\r} /v /~, <br />} <br />U07'iti / !1 1! l~ <br />~~ <br />? zGA10?#R ,f>~IlPf4ik .. ..r asr~,a.. R!?FnfiT i,F N$R r; <br />%h CJ!'". "!STi ;ToL75f , <br />cc <br />REU <br />RTC .. -.:~ ak,•: ~,.., <br />.. ^cc iA ~ }}4TT "rr <br />`ULLDSr SETrLFARLP. SAMPLE aRltrR: FRa4trY ^~~~•t--• {~ <br />1 <br />r ~) // <br />~ <br />~ <br /> MEASUREMENT V l ~ . ~~ I ~{ f <br />, <br /> <br />C9i45 1 ~ n <br />,;"PERMIT <br />'-~tr/a Ca30 <br />`~v``~'~1dt -z ~T <br />Cr-C< <br />fid''r`4!.`-4 <br />RND~"j?'C <br />?4 f"PC'R`r <br />!t~L~~~ KS <br />,A~~"'~ <br />:. "t'.°:. IIEST G ' VAt r <br />, REQUIREMENT ~ «!:r~ i l i Y M '•T /T AIY M a..ti r', <br />^TL f• GRP. 7•`'D SAMPLE :*S.r thr. r. ,•,tr;*e :,,4 ,-.., •: tr ,.:. •-• <br />- ( ,~1 <br />~~ <br />t <br /> MEASUREMENT t..+i <br />f ~ <br />D U'1 `t (, 1 D ': PERMIT a91#aaa g#qc#M9C:.0 ':'+.. RP't rdt':2 L'h!rRl:!r ~ 1"1 t18r("S+(, t1R <br />.~F'~L11E:AT ,'i'G "", s REQUIREMENT ~ ~ ^•~ T!1 "'T a! T ..^rs ~"'':. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO <br />ATION SUBMITTED HERE NALLY ET(AMINED AND <br />IN <br />AND BASED ON MY ~% TELEPHONE DATE <br /> <br /> <br />f'.IChaYT1 ~' fIIi~ <br />INQUIRY OF THOSE INDIVIDUAL <br />~ <br />R <br />O <br />O <br />S IMMEDIATELY RESPON <br />EA ; <br />SIBLE FOR OBTAINING <br />O <br />T <br />T ~ <br /> <br />~~ ~ G <br />~ <br />ll <br /> <br />f^ <br />; <br />jz <br />" <br />I MPLFTE <br />ACCURA7E <br />AND <br />C <br />MITTIN M AWARE THAT TH <br />G <br />E <br />NF <br />RMA ERE AAE <br />SIGNIF <br />ICAN <br />INCLUDI ~ <br />~ - <br />~ <br />9]D-87D-2712 <br />~ <br />, <br />!j~rn <br />r <br />YO!lmnn <br />FYIV PENALTIES FOR SUB I <br />FALS <br />O <br />TION, <br />NG THE <br /> POSSIBILRV OF FINE AND IMPR ISONMENT. SEE 1S U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED ~mum~~9ramnen~nr~Meen~6~orrths enC SUde 0rres up b ST0,000 entl a <br />pd yms.) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIULA I IONS (hleterence e/! ermcnmenrs nerel <br />'r L'. a', ~'^ (~.; i'. r- .n'' -. ~ -~I^~ ..~ ,:Lrn.i ~f, 'lr Ar•,r) P. ^•prv ,..T7 in ~_ Tn_v-r ~P_r.r{ A~: ~~rTp rat; i~-. <br />CL=I`~Eh. S'_c: (QCs r• ~• ]1., iD- n`ln ^7 I'"9~C g4,lr~~V.r^IT^~ rlT' r .-n^r-.__rCC c(Sl).,ar.Tm-• F'/• '~: <br />iPA Form 3320.7 (liB-95) Previous editions mey not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ n ^ D ~ , ^ ~ ^ rl , 7_ ^ ~ I PAGE r OF <br />