PERMITTEE NAME/ADDRESS (lacrrde Panrrry xomr//,oCatioa fpga,,,y
<br />NAME
<br />r•Lll ~i M~':h; AI~~ rh'c P•;Y, :•i[.
<br />ADDRESSU z~ S F R h v p :' I ti ii
<br />FACiun'''NGLY CJ 'sli•u~?
<br />LOCATION
<br />A7I:1: JEFF .l!I,~' !i''
<br />NATIONAL POLLIJTAM DISCHARGE ELIMINATION SVSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />r PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />MO DAV YEAR MO DAY
<br />FROM :i ~ it TO 3
<br />Form Approved.
<br />OMB No. 2040-0004
<br />.In "
<br />r - F'I'.h', ...LA,.
<br />NOTE: Read Instructions befo!e"Ct7Fnpleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX of nPE
<br />
<br /> AVERAGE MAXIMUM UNIT
<br />' .y MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS aNALysrs
<br />p~~ SAMPLE .... .~. ..:::.r .:::r ,: , :: ~: •, .. i' ( i.l
<br /> MEASUREMENT
<br />
<br />
<br />ti 1. f U it I '.I I
<br />, V'"n. ~ Y' #~y ya
<br />!. T4 ~Y.~+. N6~jyy y~
<br />'."T'gi~~~R?::
<br />"
<br />~ 4~' y
<br />.. . ~#rii ~ /~
<br />• V L
<br /># ynyf y
<br />i 'i ryr~~~~}}
<br />P ~'1 4
<br />tF.°L[iF:NT 6H.i=:, Uhi.U+; flELI(ll f(NT :v.. 4 A Ft
<br />':iL?US, S'OTAz. SAMPLE - -- ~~ ~~ ". ;t r•.~:ftltN~ ( ,,)
<br />-;3,'L: ,y ~f,•9 MEASUREMENT
<br /> "
<br />v
<br />:FLUEvT GRDSS VALUE .:
<br />.
<br />~-
<br />LIi?$, SF:TTLEh!-Lz. SAMPLE .. .. .'~.f ': •! >}C1>4Ch ~
<br />')
<br /> MEASUREMENT
<br />,:;~y5 U U ~~i .;,t~ r+oF~11~4il~' #4rCra0e ;. #~ RT"~:> .;RE`P~R'1' CE/ RAtS
<br />' F'LUii:~T c:k0°;3 V5t Uh
<br />y 6MENt
<br />.. :.,, m ~' .
<br />)ii. i~ -; !, `.ASt SAMPLE - ~~ ,t [: r: ~: a:F Fy~14 ::[:;: ( r',}
<br /> MEASUREMENT
<br />~~-55L L D v , ti ~~~. o!# .o#a#trn ;-:- ..#a~+~eaFu.
<br />°FLU?tiT GR0~5 YA Uc =~ `~~ -. ~•`' ~~ ~ - ~ 3'
<br />i~7.'+, 70TAL SAMPLE .,. .:tr :;: :'t :, :.t ~ 1%')
<br />(A :; F 4) MEASUREMENT
<br />
<br />,.<.. ~" . Q s
<br />«#F „
<br />,,: .
<br />Y~
<br />eke
<br />~_
<br />.r t LI;En'C Gk05S YA' ut' t
<br />>; ~*". ,,,
<br />H ... .... .. ~
<br />,
<br />.`°., ,;~5 _ ,-
<br />' 7a, Is CUNUUTT "'
<br />h
<br />SAMPLE
<br />.. l
<br />f 1 •. ...,...
<br />~ ... .,. ,•. ;.:,...:,,.
<br />'~, r. C T n ": A T ".; °_ N T P L A 1! C MEASUREMENT
<br />i1.i77 1 U U y` a
<br />
<br />` r,;~~g¢$1:~:
<br />
<br />' ` ~t~k4ia#rs. ~bqt#~64.~ 44t+~~t2
<br />...
<br />~•= ~K~'Y S'fi+il~l
<br />`F'FLl!..''T ;5055 VL.LUd .
<br />' ` _., - . ':.y.y.. xr x
<br />IL F, 4:. ::AE.45F: SAMPLE ."a':^ ( ;l:) ..... .... ._ .
<br />/ : S C A L MEASUREMENT
<br />',u6o L v o ~ ~~ ~-•
<br />-` _I .~xa###~x. aoaaa~x +a~t~#a# •.~:• L'~" TS~Jt
<br />L
<br />°FLOF,'iT 65065 U U" '~~"~ ' ~~ s ::t
<br />"n
<br />• ;
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICenify under penelry of saw that Nis document and all attachments were
<br />prepared under m
<br />direction or su
<br />ernsion in accordance wiN
<br />si
<br />n
<br />t
<br />d
<br />tl TELEPHONE DATE
<br />y
<br />p
<br />g
<br />a sys
<br />em
<br />e
<br />a
<br />I
<br />~~
<br />Q
<br />1
<br />s to assure that qualifetl personnel properly gather and avWUate Ne information _
<br />~
<br />submktad. Basco on my Inquiry at the person or persons who manage the system, v~
<br />;
<br />l~
<br />~
<br />~
<br />p
<br />~, or Nose paraore olreclly rasponslble br gaNaring Ne inbnnatlon, the iMOnnellon
<br />E ~ r
<br />'~ =
<br />~
<br />r ~ / f eubmMed la
<br />tothe best W my knwAedge end belies
<br />true
<br />ecnirrme
<br />antl complete
<br />` ~ 1 ~
<br />1
<br />"~~
<br />U
<br />~ v
<br />,
<br />,
<br />,
<br />.
<br />,
<br />l em aware Net there ere
<br />i
<br />nifi
<br />eneltiea br
<br />rt
<br />b
<br />iN
<br />f
<br />l
<br />i
<br />f
<br />i SIGNATURE OF PRINCIPAL EXECUTIVE J G I ri a
<br />g
<br />s
<br />rar
<br />p
<br />su
<br />m
<br />ng
<br />a
<br />se
<br />n
<br />ormat
<br />on,
<br />TYPED OR PRINTED
<br />Incluoin tl» ssibili ofhre end im nsonment br knowi violations. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />wmmcn 1 a nrvu terLnnF,1 turv ~r arvr wuln l luny fnererence an arcacnments nere/
<br />!'~~ f. 7;)fnL I''~i LI9IT5 »ILL .°. •AIVr:^, p.tin _;:T"LFA.:'7.F )LIilS LI°:: drf`LI':: FO'; C=1"t;.,.14ak PkL'C1'r °V".:.:-
<br />.A.1, f , FC f' 7 N7~. AIL ~ A.,. ?.'_2C•pTI'r~ ;S'F' ..,, ? ~
<br />` ="""~ E '~~` `~ .. ai.F, VII. fLY ~ABPLING
<br />EP AL 3 9)` Pr vlbus etlitio r6ay be used. THIS IS A 4-PART FORM PAGE OF
<br />007R3/U!?0717-1350 I
<br />
|