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PERMITTEE NAME(AODRESS (lnchde Facility NomeJLocalion iJDigerorQ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />NAME DISCHARGE MONITORING REPORT (OMR)
<br />c!LUG fi Oil .'.: AI'. !'.L F..':Y- 7N~_
<br />Form Approved.
<br />OMB No. 2040-0004
<br />ADDRESSU cSF RA U7 ~+j4'~ - -- •-n r~. ~ (SGyii .'; il)
<br />J %; U! C D U N "' 7 1%C) A :; (~ 5 PERMIT NUMBER DISCHARGE NUMBER r_ F 7 .. A L :+ .+ L
<br />i'AN:;LY ~ J ``16'~1~ MONITORING PERIOD
<br />FACILITY stn-? LOA:rGCT ": ?tP :F..~;
<br />LOCATION ~ YEAR MO DAY YEAR MO DAY
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<br />NOTE: Read Instructions befor
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX of TYPE
<br /> AVERAGE MAXIMUM UNIT MINIMUM AVERAGE MAXIMUM UNITS aNaLrs/s
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICertiy under penalty of few that mis document and ell attachmerrts were TELEPHONE DATE
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE g
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<br />TYPEDO RINTED
<br />Includin the slbili of (Ina antl lm risonment br knowin violations. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS ANO F,(PIANATION OF ANY VIOLATIONS (Reference all etlachmen)s here)
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<br />used. THIS IS A 4-PART FORM PAGE OF
<br />90567/000717-1350 1
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