|
PERMITTEE NAME/ADDRESS (Include Fanlirc Nome/Location ilDifjrrenf)
<br />NAME TICY cTNth: FhCC E~S Ih:,, Lil
<br />ADDRESSh }; F ELK n l A E
<br />~T7 :•t+F.l~urrr rSTVC ~VU ofy~h ~i't r+-
<br />FUIh~$Y~„T1,,,,~1 iN L]7l2
<br />FACILITY ~ Y
<br />L¢><...
<br />LOCATIOt~u ~..~N g~"" , 4JSILCC E3091
<br />~-
<br />NATIONAL POLLUTANT DISOHARGE ELIMINATION SYSTEM (NPDES) Form Approved. -
<br />DISCHARGE MONITORING REPORT (OMR OMB No. 2040-0004
<br />(2-t61 (1].91 riech •
<br />~ ~ c ' ~' a; 1 S U E F : F) APProval expires OS-31-98 ..
<br />PERMIT NUMBER T; ,if,~, DISCHARGE NUMBER F - dY~11 l~f:k~.
<br />MONIT~ ERIOD CCIltSIC ~FYACE 7C FC1C CCt
<br />YEAR MO DAY YEAR MO DAY `""
<br />FROM . ~ : TO L ' ~ c ~ ~ NC C :' _ : r :; } : ; (1w,~ 5 rt~ 5
<br />(zc- ~ ttiz3) lzes6l (z6~zr) (ze zs) 138-3p 4 OTE: Read Instructions befoFe completing this form.
<br />a~ / c r : ,. }s r~
<br />5 (3 Card Onty) ~ OUA ITY QR LOA If) !< Card Onry) QUANTITY OR Z~ONCENTRATION NO. FREOUENC SAMPLE'
<br />PARAMET R (46-53) ($q~61) - (38-45) (4653) (Sf-6/) EX OF TYPE
<br />(3230 AVERAGE MAXIMUM ITS MINIMUM AVERAGE MAXIMUM UNIFS
<br />ls2-631 ANALYSIS
<br />(64-88) "
<br />(69-70
<br />./ill, 5-CFI SAMPLE S: r,;:>:.^::: F~ a aa5~:;:. ( 1.)
<br />(c !; ~ ~ V . C) MEASUREMENT
<br />~ S1U 6 U G
<br />P~Rt~rT ~ b0 : ~ LPFSL:b~ ;' is
<br />
<br />~ t0 GFLCTiY Y .~ )l -
<br />}` ~i1E..
<br />
<br />"
<br />~t~ILFLCi,FACS CrF17 flEC1tJ1Ei ANY ~ ~;: -5aa
<br />° r Ilt bV4 ~~- ~'- CG/I .
<br />rr, SAMPLE 5'40 aa,;::;:} Xa{.;.:,C ( li)
<br /> MEASUREMENT
<br />'U4UL` A U 0 4t 54<:
<br />i51i+tECT,PECS CrrLI , t71Ht;M18~lT a ^" ,',,; ~ ~
<br />~
<br />" L4+: dTAIiF ~ l1A~r~d[t`°"- ~C ~ ~~
<br />3viI~S, TG'TAL SAMPLE 'SK:G yl aaa4L'a .: caa ( IS)
<br />l: 3 F k h D t .: MEASUREMENT
<br />~
<br />,. C, ~ 1(. A v t; ~ ~ ~CAMIr o o a f~, x, , : ~
<br />LSI:yELC'1,r'hC5 CrF1'i .(3~QUIEidM~~~ ~
<br />~ ", ;a
<br />_.. +~ ~'~ i'6/! ~~~~ ,
<br />;IL A::G GhLASh SAMPLE '`aara'~ ''Sa'S,; . cacaaa 1 l5)
<br /> MEASUREMENT
<br />' )50l A U 0 - iC - # 55t ~. iC+~ '~!~'
<br />~ -M~31r ~F~..-
<br />ISI:"F~~CTrFflC`_ CCF3,7 ~BQCIH~iVfEN~'• ~ ,=N3-S ~3~ Yt:}i, ~"~-
<br />.~
<br />~_ 1..~, `A ~t~_~Y. .G/I _ ~ ~'~
<br />~L.:., iN COUGOIT CF SAMPLE 1 03) Ld0:0 caaaaa vGaaao
<br />:: t~U ':FcATt!ENT FLAA9 MEASUREMENT
<br />U~t'J F
<br />FC
<br />i S 1'i F :, C'f , E f+C 5 C r F 1 T ~EQUI(~hfAEt~. '
<br />::LIt'tJ ", F°CAL SAMPLE arta~a=F ar,atlaa .:: a:ao 1 I.)
<br />k. It t ^. A L MEASUREMENT
<br />7ut,5° R U C ~: ~v~~~ll+`'' * Mt~Fs.>,
<br />~` tri >O4a~a9~P-~ -(,~ ~/ .: ]t6.~ .
<br />t.:T'IF.:c•:
<br />Fhcs cr~t~ '61GGilJIAk~1~~` j r• .4s'' ao~ ` ~
<br />~~~ 1cCrI .=' £`it' >~ ~`
<br />, , K. r , .
<br />~iL i; ti,. ~, I~t:ASP SAMPLE "AC4+: ~7Y ~ ( 9(y) ..~4 ?'~C YlaLaa a+;55 aa.
<br />I ~ J A L MEASUREMENT
<br />.; G L I~ `r i. U U: ~~ '4ERTv11T• - 1; ~~
<br />'~~ k ` `I :O~ - ~i .11 "-~° ~ ' a U ;! ~~~ 2. ~~Rr~Q-~'I:
<br />! i :; L h k L C T, F H C 5 C r. l' 1 9 ~~Qlil1l"FJe1,~.N~', pf
<br />t
<br />'. -
<br />..- D C= C " "'~'" r k,"_ •'.
<br />-~ S =. 5 ' n„-r +-
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF I
<br />AM FAMILIAR WITH T
<br />E INFO
<br />M AW THAT I HAVE PERSO
<br />ATI
<br />ON S
<br />ED HERE NALLY ENAMINED'R
<br />IN
<br />D
<br />N TELEPHONE DATE
<br />H
<br />R
<br />I~
<br />UBMITT
<br />~ pp
<br />IN
<br />FOR
<br />EVE 7H
<br />171- v ([ ~K ~ r /~ ~ ~ t ~ AHE
<br />'
<br />D
<br />P
<br />I
<br />W
<br />E~
<br />H ~
<br />; AND BASE
<br />M
<br />O
<br />A
<br />E
<br />~
<br />~
<br />p
<br />~
<br />~ I~
<br />U
<br />M
<br />AND O
<br />MPLETE
<br />T
<br />HA
<br />T
<br />T
<br />A
<br />AR
<br />PENALTIES FOR SUBMITTING FALSE INFORMATIO R
<br />ERE
<br />S GNIFlCAN
<br />N
<br />INCLUD
<br />NG THE ,~(
<br />~{
<br />~" -
<br />'
<br />,
<br />I
<br />)-'t n 1 !~ rt,L ~ POSSIBILm/ OF FINE AND IMPRISONMENT. SEE 18 U S.C. § tODt AND 33 U.S.C.
<br />' ~"
<br />r~-~
<br />IGNATyRE ~F PRINCIPAL EXECUTIVe
<br />2 4-
<br />U
<br />Z.L
<br />§ t318 (PaneN
<br />es untlel these statutes may inclutle lines up ro 570,000 antl or
<br />TYPED OR PRINTED maximum impnsonment of behveen6monMS antl Sysers.) OFFICER OR AUTHOR2ED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all eaachments here) ~~ .;:~
<br />!:, i`AY AL'EkAGE IS i'IGEkST r,CATh1Y AYG. UUSIbG PFhICL' HEICF7F.
<br />tG31 E ChEA.SE - `EE T.E.l.C, I. :.
<br />nr
<br />EPA Form 3320.1 (08-95) Previous editions mayaer'Se used. (yEPLACES EPA FOAM T-40 WHICH MAY RIOT BE USED,) ~ PAGE OF.
<br />
|