|
PERMRTEE NAME/ADDRESS (Include Fociliry Nmne/Locmion /fDigerenq
<br />NAME ^v• .Ir vA. ~• v .. ..~"'.
<br />ADDRESS~`1Iy-;:. ),~; •:J ^nrJr•,e _. r'
<br />FACILITY
<br />LOCATION
<br />
<br />NATIONAL POLLIffAM DISCHARGE ELIMINATION SYSTEM (NPDES) Fortn Approved.
<br />DISCHARGE MONITORING REPORT (OMR; OMB No. 2040-0004
<br />lz-1e1 i1~- s) v ~ 7 "" Approval expires 05.31-98
<br />PERMIT NUMBER DISCHARGE NUMBER _ ^ r ~~ E T n'1 ~ "~
<br />MONITORING PERIOD v -." ~ • ., ~•.1 ~ ~ o,.1T l -' ^ n c r
<br />YEAR MO DAY YEAR MO DAY _
<br />FROM .v r. TO "a 7 an 2A~ ,.~ r`. ~t.,.4^"v , } ryC ~ :Si
<br />rzazl! (zz-za) (se-zs) tzs-z» !ze-zs) (3aJr) NOTE: Read Instructions bef ~ co leting this form. ~; I. " - .
<br /> (3 Card Onry) QUANTITY OR LOADING (4 CeM Onry) QUANTITY OR CONCENTRATION NO. FREOUEN SAMPLE'
<br />PARAMETER 46-53 54-61 (38-45 4G53 54-81 EX OF TYPE
<br />~~n AVERAGE MAXIMUM UNfTS MINIMUM AVERAGE MAXIMUM UNITS
<br />(92e3) ANALYSIS
<br />(64-68
<br />6&70
<br />t'„rt.~ .:r.,. ~. SAMPLE r: Y: G•.Rrc caxx?" r.,. *,~.... ( y•1)
<br />(A5 " ') MEASUREMENT
<br />O 1 D 4 g ~! () ^. PERMIT. 4 C--; '4`4
<br /># .p~ ~~'~ =R1! PC)9S 1' . ~ ~~:
<br />-EE CO`; ne'f 7i REQUIREMENT *
<br />s;. ~ ~ a R3•:G _
<br />~
<br />i ..
<br />'~QflI~
<br />' ,
<br />~~ rr,i *, t ~t^N
<br />~~„
<br /> ,
<br />,. f""~
<br />;~ ,+'~.t iB
<br />.3 +
<br />y a
<br />IP.Or~ Y'~7:'... SAMPLE 4C#RF.C e+T/:eJ<t# #17fi"n~ ( {q~
<br />(P ~") MEASUREMENT
<br />D134S 1 D ~ ';'``~PEFNII~' 44K+¢~Ik
<br />'
<br />~
<br />`" «•xG O ~a ~:.
<br />~ `~ ~.k :. ~
<br />~ ~ , ,
<br />~
<br />~FPLIiF,`IT GTI'!"5 Y!11.r1^ REOU~HE ENT
<br />M K r'~„
<br />``
<br />`i; ter-?
<br />O' ~°+
<br />~r "
<br />~7 ~~5"AY Yr yy~~
<br />',bx
<br />9^,/T ~
<br />~'
<br />Ft, *~r
<br />`
<br />.y ~^
<br />'rLG:, 7!4 COyJnTp '1" SAMPLE { n31 ~`?r''~* ?":t.4R4 h±'k!~"
<br />~•q IU TRFA?17S'pj or. '. ',* MEASUREMENT
<br />S(10~•'J 1 0 'd l PEFiMllid EPORT ~?qAL "' 4t+~4tl!~ 4-O'bRrttFlt ##>1~~, 4..... ~ P.E'~ F,'~~ ~i
<br />'FFLU1i'iT :°054 VS'.11` REQUIREME~1
<br />; A ~lIG f R1S MGt1 ' (_ t0+'? ;{"'~;
<br /> ,
<br />ESL AN7 .k°.AS? SAMPLE R:;:rt~3[: { 99) `-'I:y+~:~ .~~..;...~. .....':r.`::'.
<br />': I ~~ IJ A L MEASUREMENT _
<br />q
<br />~, ll ("~u 1 7 D
<br />":
<br />PERMIT
<br />, M
<br />"4'CtOCnRR
<br />-,
<br />."~„
<br />,,. T
<br />~_
<br />""'L
<br />
<br />C~4Ar#td
<br />-+'
<br />r.. C#
<br />
<br />"~4tb$~ti4c
<br />
<br />;:~}'~
<br />
<br />-
<br />K q
<br />T
<br />,
<br />t? R17
<br />
<br />
<br />ffi~~
<br />
<br />^: t.l'C'v'.• !;n1S5 Q~. ).'1' -,
<br />REpUTAF~MF~ .
<br />"°
<br />I(4Y
<br />~•n_n
<br />~~
<br />i .
<br />v..y .: .. ;
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT ~
<br />f ~ `'~' -
<br />~
<br />~ k
<br /> REQUIREMENT - -
<br />ns?';." °. + ~ ,'=
<br />, ~~r
<br />A
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ~ -:'
<br /> REQU(REMENT
<br /> ~, -
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT
<br />~ - .. 'S}.$+~
<br />~ ~~-
<br /> REQUIREMENT -
<br />s~Xe,
<br />-
<br />,
<br />NAME/TRLE PRINCIPAL IXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY TELEPHONE DATE
<br /> I
<br />F
<br />D
<br />
<br />2lchard i'1III5
<br />• THOSE INDIVI
<br />UAL
<br />NQUIRY O
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPON
<br />E THE SUBMITTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE,
<br />
<br />/
<br />J
<br />~
<br />E
<br />f
<br />`
<br />P ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTIN 1 AM AWARE TH47 TH
<br />G FALSE INFORMATIO ERE ARE SIGNIFICAM
<br />INCLUDING THE
<br />N ~
<br />/
<br />'~ J]~-B]Q-Z]17 (~ '1
<br />r
<br />hvironmPr.tRl
<br />.
<br />ar~a POSSIBILITY OF FINE AND IMPRI ,
<br />SONMENT
<br />SEE 1a U
<br />41001 AND
<br />S
<br />C
<br />U
<br />S
<br />C ~/
<br /> ~ under these e .
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />07
<br />ret
<br />t
<br />I
<br />l
<br />d
<br />M
<br />b E10
<br />000
<br />d SIGNATURE OF PRINCIPAL EXECUTIVE
<br />TYPED OR PRINTED u
<br />es mey
<br />nc
<br />u
<br />e
<br />ev up
<br />,
<br />an
<br />d
<br />pnsmmenl or 5ehroenamprtha erM5yeers.)
<br />mex/mum i~~ OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence ell effachments here)
<br />f•Li.:~'~A"` LI'ii7 '~ ~~e .'7'i nS"T(,ca4f.F i7L~D~ (L3' rn~1 f.^'~f.Y r....c ~ ~_ t'1-r ~q_N.. - .^r~ ..
<br />~ ~~~iT
<br />'[`.~ CLAIr. ., l'.• ~°p .•.. as `0^ To, cnn ~•I n:1 c'y l° ~o'17F r.c~l.Tn T'w..N.,^~ O7i a ,-c.c ire_--.. .,,n.1,r... 1~..c^r/ f" ~.
<br />e
<br />IP.sr V •'r11 T C ~ e
<br />EPA Form 33261 (0&85) Previous editions may not be used. ~ ~ ~ ~ (REPLACES EPA FORM T-4b WHICH MAY NOT BE USED.) O D ~ ~ n ~ ,~ ^ ~ H ~ ,~ `) ~ , r PAGE OF
<br />
|