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r~'"TTEE NAME/ADDRESS pk(ude FaAliry Nmnv/LaroGan i~Drgerenq <br />:SS .~. _ u I, <br />~ ~ . .~ <br />m <br />~~rv '- _._ <br />~ -ION <br />~ - ,L ~ i <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPOES) Form ApprOVed. <br />DISCHARGE MONITORING REPORT (OMR) OMB No. 2040-0004 <br />. ~,..._, ~ r~ ... rl <br />PERMIT NUMBER DISCHARGE NUMBER _ <br />MONITORING PERIOD ' ~ ~ -~ ` - ~ - <br />YEAR MO DAY YEAR MO DAY _ <br />FROM _ _ i ' TO ~ ~ _ ~ ~'. <br />NOTE: Read Instructions before comlpleting this form. <br />~ QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREDUENC SAMPLE <br />PARAMETER EX of TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANUrsIS <br />I. .- .. .. 'I ~, C <br />~: _ SAMPL E.. r -, ... ( +. <br />1 <br />.. ., ~ .. .' MEASUREMENT ~ ~' `' ~ p .j~ - <br /> PERMIT ~ ~ '- -- _ - _ <br />~. h r , - ' '" ~ REQUIREMENT ~ - <br />'yf) i .-~., ~. ,'I;. `C SAMPLE ~ <br />J <br />l ) ~ j v ( i~ '/ <br />' ' <br />v~ <br />~' <br />. - L ~ . MEASUREMENT (, <br />J ! /<'. - <br />.. .,C ~- L .. PERMIT :r :: ~ ~, .. ..: .. _ <br />-'.I ~ - , `I , REQUIREMENT .. ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICenity untler penalty of law that Nis document antl ell attachments were <br />tl <br />d <br />i TELEPHONE DATE <br /> <br />~ prepare <br />un <br />er my tliredion or superns <br />on in amortlance with a system tlesignetl / <br />~ - <br />~ <br />GtIV / I -~~\1./.- <br />I - tp assure Vtal WaliT~ed perwnnel properly gather end mNUMe the xttortnetion <br /> <br />submMed <br />eesatl on m <br />In <br />ui <br />of the parson a pereom who mana <br />e the s <br />alem ~ <br /> <br />~ - <br />~ <br /> <br />~ ~ <br />I I <br /> <br />/ <br />~ <br /> <br />, <br />, ~ , <br />~ ; . <br />1 . <br />y <br />q <br />ry <br />y <br />, <br />g <br />or those persore tlirec9y responsible br geNaing the inlormation <br />the Inbrmation , ~ <br />C <br />y f ~ ) ~ ~ li <br />, `~ <br />.., <br />, , , <br />submilletl is <br />to Ne best of m <br />Imowled <br />e end belief <br />true <br />accurate <br />lete <br />end wm ~ ~ <br /> , <br />y <br />g <br />, <br />p <br />, <br />, <br />. <br />l <br />h <br />h <br />l <br />i SIGNATURE OF PRINCIPAL E%ECUTIVE <br /> <br />TYPED OR PRINTED am aware t <br />at t <br />ere era signiegnt pena <br />t <br />es br submitting false lnbrmation, <br />includin the sibili of One ens im risonmenl for knowin Notations <br />OFFICER OR AUTHORIZED AGENT <br />DE NUMBER YEAR MO DAY <br />COMMENTS ANU E%PLANAI IUN Uh ANY VIVLAI IVNS (/iateTence all atfachmentS Here) <br />'' - _ ~ a - <br />EPA Form 33T0-1 (REV 3/99) Previous editions may be used. ~ ~ ~ ~ ~ T THIS IS A 4-PART FORM PAGE OF <br />