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PERMITTEE NAME/ADDRESS (include FaclliryNmnr/focarlon if Digornq
<br />NAME
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<br />ADDRESSCrSc:?ADa YIR';
<br />.3607 C'!Uk:Y d•JAJ 5S
<br />FACILITY I A N .G L Y C w y 1611 7
<br />LOCATION
<br />,ITh: JEFF i.'L-~' ;c•r
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MFDES)
<br />DISCHARGE MONITOgING REPORT (DMRJ
<br />7 ~ ~
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM - ^ 5 TO ~~ 1 O $ 31
<br />Form Approved.
<br />OM8 No. 2040-0004
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<br />NOTE: Read~lnstrudions before Tcompleting this form.
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<br /> QUANTITY OR LOADIN QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX of TYPE
<br /> AVERAGE MAXIMUM $. MINIMUM AVERAGE MAXIMUM UNITS aNALrsls
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICertiy under penalry of law that this tlocument and ell attxhmenis were TELEPHONE DATE
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<br />r prepared untlar my tlirection or supervision in accortlance with a system tlesignetl
<br />to ensure that
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<br />ersonnel
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<br />ather end evaluate Ne inbrmalion
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<br /> eubmittetl. Based on my Inquiry of Ne person or pereone who menage the system,
<br />or Nose persons directly responsible for gaNedng Ne inlonnation
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<br />aubmlttetl Is , to the best of my knowletlge end belie( true, eccurrtle, eM complete. SIGNATURE OF PRINCIPAL EXECUTIVE r~ 7~ ~ (, 7s ~-y 3 G 1 '6 oZ C
<br />TYPEDlSR PRINTED lam aware Nat there ere significant penalties for submitting Isles inbrmatlon,
<br />inclutlin the sibil' otfne end im risonmenl br knowin violations OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />.._ b TOTAL I;.?e LI'.I'fi; BILL EF. •Ai'+~f~r AtiC :?r:Tl,i'AfL°. ~~~LLL:> LI°i"I A[iLIE~ FOi? <=101A~2uNu ~k'cC~~ ..~.~--
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<br />be used. _7~SYt15.A4PARTFORM PAGE I OF
<br />UC491/0007
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