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PERMITTEE NAME/ADDRESS QMrI.FrWyNsW/,ar•ua pD~.r.•0
<br />NAME !;JS_:'. t, _ ~'L. .. ~, ~. PJ !
<br />ADDRESS ~' 1 ~ ~ ~ - '
<br />FAaI-m
<br />LOCATION
<br />' ~ . /:J
<br />NATIONAL POLLUTMT OISCHMGE ELIMINATION SYSTEM lNPDES)
<br />DISCHARGE MONFFORING REPORT IOMRI
<br />I1-161 17-191
<br />~J;dCi0~1] 3 ~.r
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM '/ 7 V! ! I TO Y d J'y ~ U
<br />116111 l11-731 !14151 !16171 l18-191 !363/1
<br /> Fonn Approved.
<br />~~I?? FONC u'7VQ~~ OMB No: 2040-0004.
<br />iree 05-31-98
<br />Approval lixP
<br />(.i U d 3 :~, e) .
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<br />~1 Nll :`.
<br />
<br />NOTE : Reed Imtructlons belore completin8 this form.
<br />PARAMETER !3 Grd On/yl QUANTITY OR LOADING (4 Grd Only) QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
<br /> ley-531 154-511 l38-451 !46-53 !Sa-511 EX GF
<br />131371
<br />MALrss TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS Is]-s]! /5{-681 /59-701
<br />:I;iJUCY'iV1TY SAMPLE ~ k?:; :: ?~~}~`-kr~ l:kG::4~ ~. ( 11) Ia
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<br />MEASUREMENT ZN -So Z ~Rn3
<br />JJ11~Y 1 U J PERMIT ~~k P~C3;k ^;-'r-~.SG :} ~#^- 'k3~ri GY: :#~~>r # D
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<br />c.r'rL'JL'ni ,;EU35 VALUE REQUIREMENT. ~~ ~ ~ ~ BAILY ~K1I C`!
<br /> SAMPLE Sr.v ~O~ ..^•S4;t:
<br />Y•Y ,.
<br />( 12)
<br />3
<br /> MEASUREMENT ~r31.t ~E$Q 1
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<br />)~aJJ L J ) PERMIT #+XPR4:b #O~Y-0td4IF. . OS: 5..5: >:Sf.:#. O
<br />9.0
<br />4
<br />F.E.F.LY
<br />'KSITU
<br />-}~iELJdNl 1K'JSS 'v ~.L 1', .REQUIREMENT ~ ~ ~ ~~ #At~Ip 9I~NI>hUiS ~ !iA1fI!lU~~t.. S!i
<br />~JLi USE iETTLEA .. SAMPLE -`+RC:L+'• '?:<Y 4+`-,`- G::~Y-?-'- .-' C .';•
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<br /> MEASUREMENT L_ D15 ~ G(2, ~~~
<br />~tiSJj • U D PERMIT .«:.r S~k ~k {t (c~x:kG
<br />Y .. ,'v k;F:F ;: .-.. ,- ,- Q~K i '3 :)t/ :T~'~
<br />:f'FL.JEN1' GftU$S VALI; REOUIREMENT r,:{: ;; .DAILY Kx .'1L/L !')?3?'
<br />11L ANU .;KE9S:'. SAMPLE # k-".~:~5 ..:G,^-~G ;c ~k :;: ~;: 4::.' ;. +~.: ..
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<br /> MEASUREMENT A A
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<br />33'a r;2 1 J J .PERMIT 'k;:. xnY -.~~•~kx ~4 rc!. ~,f:g:.:+:: s:: ~:. ,- ,. 113 t O": ?"N .a
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<br />cY'Ff.UENT ,;aJSS bALUC REQUIREMENT -.`•+::k DALLY YY 9:'/L '
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<br />L.J R E L fl L 7 ll U d l ~' J -' SAMPLE ( :,:, J) v ~~v" v:.-
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<br />r::In.J '1'kEAPrFNT '."LA'tiC MEASUREMENT Q1~q+~L 2
<br />p031$ ~
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<br />,)J iJ 1 D U PERMIT 1PYI7.!1A:L K~P)(tL Yk-,Y##~C= +~-'.-:~>s 4 `.-f: t: !:tk= = '4~'+c ~~},/ 'YSTA'4
<br />. E'tLJ!:;r7 JK7S:, 7Ai.'i'. REOUIREMENT 3DD6~ AY;, ~AtI4[~ r.x MGD ~ ra.#
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<br />"~~.i.l USE TUTAL SAMPLE •rk~:c'k R##xa# ::## 7;F
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<br />> :; J L'! G ll MEASUREMENT `~ S ~ ZOZO z aQnL3
<br />1UZJ7 L U J PERMIT 5c {:RX=:: :=~i-71i.R # '.%C".: )L'TIJNi1L r:### =y: ~$P4)s<T J ( ' SLY .r{R^,
<br />.F^L;:rNi v.%;].i:i '.L;: REQUIREMENT 2:'r'k ~RT3 Afrt. UAILY RX M:/'_
<br />/1.. NU ,:AF4 ;r. SAMPLE ~••. •• ( 9J) :~~:~:.~ ...,.k -:~ ..... 1
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<br />MEASUREMENT 3
<br />~/I SUA L
<br />-+'1h~ 1 PERMIT 4r~•r°kR '.?i?P'v1RI Y f~:,=1 C-r:t;7:? ~Fvrfi # .e"I': ;:1,`: -k':, f Vf'~/ L:};IAL
<br />-:. L: L: a': ..%JI: i.'I ~. REQUIREMENT jti ,i l' }IAY YC=U ,. y7t,j;
<br />NAME/TITIE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENN.TY OF L AW THAT I HAVE PERSONALLY E%AMINED MD TELEPHONE DATE
<br /> AM FAMILIM WITH THE INFO RMATION SUBMITTED HEREIN; MD BASED ON
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR -, '
<br />~
<br />:Ichard /NIIIc OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE, ACCUMTE MD COMPLETE. I AM AWME THAT THERE ME
<br />SIONIFICIWT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING /
<br />, /r
<br />! ~ - .~' _ ,' ~~7/~f^r
<br />I'!~VlrClil P1P_II ~.I ;~.a f17:]@r ,
<br />THE POSSIBILITY OF RNE MDIMPNSONMENT. SEE IO U.S.C.11001 MD33 '~ '~°" "' O
<br />SIGNATURE OF PIIINCIPAL EXECUTIVE 7D1 " t7D-~7~~ )~ ~5 ~'.
<br />~ "
<br /> U.S.C. 1 t]te. IFMrkY1IM•r rMr moms m.v Irp.W A+s w ro E 10,000 AREA
<br />TYPED OR PRINTED ~ItlrmrHwn inpiolnwnr ofMMrnemanN..n06Yrca/ OFFICER OR AUTHORIZED AOENi CODE NUMBER YEAR MO DAY
<br />COMMCrv I ~ ANU I:APLArvA I ION Uh ANT VIOLA I IVrvJ 1ReTe/MCB eO IRICn/nenES OiE9/
<br />,, .,:iLG:1 .`+LG :ULI>:. L:°I .iIYc.• b'7R L)-YI•E 11-4't F;t .: I? .:J~, i -. ~:.i ....T .C) R;~~J^. ._ ?~')OF u•, )I; .: "[ •T"~ L~
<br />-.•nl' I. t1. l.uE 2J. .. .;P:I~~,xe4T :.. ".ii~(nCc''e'1T ^LRti DPI 1-1-ai3.
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<br />EPA Form 3320.1 108-951 Previous editions mey be used. IREPLACE6 EPA FORM T-40 WHICH MAY NOT BE USED.1 ), t ,i ,- / .r T ; I ~ t ~ - t ~ T :i PAGE - OF
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