|
PERMITTEE NAME/ADDRESS (Inclyde Fan(iry NamdLorn(ion ifpigerenp
<br />NAME
<br />ADDRESS I) .. F k A P ;J r; I :::
<br />NATONAL POLLIfrANT DISCHARGE ELIMINATION SYSTEM (NPOES)
<br />DISCHARGE MONITOgING REPORT (DMR)
<br />.•-.,)+.
<br />•.+n-, ,r
<br />PERMIT NUMBER DISCHARGE NUMBER ,(~ ~ ,~ M )
<br />- F'I rh:.
<br />Form Approved.
<br />OMB No. 2040-0004
<br />:'-LO '.
<br />FACWTY nn n~~l.a ~:J r!'., ~ MONITORING PF. IOD ~`'-= .'l-J^ :~TG.~hGF. T'i i7 .';' ~A". 11
<br />LOCATION Y MO DAY YEAR MO DAY
<br />_
<br />FROM r)i U1 TO '1 `; ~ .. r: ~, ,~: i,r .r i, hr. ~; ~ "'~~'~
<br />e
<br />85rhpleting this form.
<br />A f f N 7 J ?: F F :i J 'i'+:. ^. ?' NOTE: Read Instructions befor
<br /> QUANTITY OR LOADI QUANTITY OR CONCENTRATION NO. FREOUENO SAMPLE
<br />PARAMETER EX OF TYPE
<br /> AVERAGE MAXIMUM MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
<br />.{ SAMPLE rp r:.; .. .: r: r: :, a::a <: ;: ~,': r~:::v (
<br />)
<br /> MEASUREMENT ...
<br />
<br />UU4UU 1 0 i
<br />'
<br />•
<br />' 'p
<br />~~~
<br />`
<br />~
<br />~ „,~~
<br />' '~ '~ i~
<br />"'~ ~.. ~..i!~~t~+tr 9aQ - ~i~ '11~i,'~'~'
<br />F F L
<br />J F.
<br />. I v p D
<br />; S 'Y A 1. J
<br />y [A
<br />1
<br />Q
<br />~
<br />
<br />.
<br />.~y.;
<br />.:' _
<br />,
<br />
<br />~DLID~ TOTAL
<br />. SAMPLE ....;... ., .. .. :: ~..... .: r.^ir~R
<br />4
<br />(
<br />1~~~
<br />~'):iPE`:;iEi) MEASUREMENT
<br /> £
<br />r M
<br />Y:?F LU~n vHDSS VALU.
<br />I .
<br />-> %*- ~ ' r } - "`.
<br />~iLICr;, .~TTLF.4?:,5 SAMPLE :,`•: ~;t :. ;~y.p ( )~+)
<br /> MEASUREMENT
<br />u^5u5 1 0 U ~. ?ir4la+Wbo
<br />" ~vntagla aa~re~lb
<br />' ~t<
<br />~ ~ ~~&~ R
<br />FFLUF.:~f GRDSS VaLL' ~~ ` . v _
<br />''iL 6 I; ^; F.ASF, SAMPLE ... .. ~i ::.; ~::; e° t:kG#r/:k
<br />( L ')
<br /> MEASUREMENT
<br />~J'/S~L 1 U U 1((Iq?R. 'IS>W arstge 9! rk#IRI#ri4 - ~:'. ..
<br />:.F'F'LL'E!.T GRUSS VALU" ~ - _
<br />- ~ {° G
<br />I::,)::• ' r SAMPLE {::~::...;:, O
<br />( q:; F c) MEASUREMENT
<br />I,: uuS I U 0
<br />, #OrigMt#,- ,..-~IP9r~Kf5r
<br />,
<br />3.L~: 1,.
<br />.~`,. .,. ~ ~ >. R~,. .
<br />:.iF'LL'L"~: GkOSS VALU > ~
<br />.y i. .. 0 Y~ _; „~ ,
<br />'~L~a, ;!: CJNUUIi C9 SAMPLE ( ~ ?1 ... ...'::~', a,~::::;::r:
<br />.:-.U IF: c.=. '':5°iV: PLA N'I MEASUREMENT
<br />`.,C .):.7 1 U U .... `, ., 4 4 :i~$1>Q'~T>.. ~ ##CL`40. 4tr#rlt ft t%O OdEl4#~ ...y _` ~~ ~$'~.
<br />• FLL'~ k,N75S V4L'JI
<br />
<br />' + ~ ~;I: t.;<:;ra
<br />ihs4
<br />JIL A(i ;::
<br />GRCASF: SAMPLE ;r r:Cxvrv ( rC) [::;: ~.:.;-~ .. .r; ra
<br />C ; S J ,L L MEASUREMENT
<br />
<br />J 4'. I V U
<br />~
<br />e . ,„'}' r<','
<br />u -~
<br />a~~~~>~
<br />iYQ~la ~'~ IC.
<br />1~!~~$
<br />ik is
<br />-y' yam`
<br />s4p~,
<br />.
<br />'
<br />~
<br />~
<br />.~•Ft.u-'.r c2D~s vAt.u. .c. ~ ~~ ,.,=rl t; -,~:: _<, ~
<br />,
<br />,
<br />NAME/fITIE PRINCIPAL E%ECUTNE OFFICER ICenRy under panalry of Ww that this document entl all attachmerns were
<br />re
<br />r
<br />tli
<br />d
<br />d
<br />m
<br />ti
<br />i
<br />i
<br />i
<br />tl
<br />i
<br />h
<br />tl
<br />i TELEPHONE DATE
<br />p
<br />pa
<br />e
<br />un
<br />er
<br />y
<br />rec
<br />on or superv
<br />on
<br />n acwr
<br />s
<br />ance w
<br />t
<br />a sysem
<br />ea
<br />gned
<br />C ~ / ~, l/ 11S t C:L~ ~ to eseure that qualified personnel properly gather end evaluate Iha in/om,ation
<br />~ _
<br />eubmMed. RaseQ on my inquiry of Na person or persons who manage the system,
<br />~l~
<br />~
<br />- or Nose persona tllrectly reeponaible br gathering Na IMOnnatlon
<br />Ne IMomution •
<br />,
<br />/ J~~' ~ }) ~ eubmMed b
<br />to the best M my knowletlge end ballet
<br />true
<br />accurate
<br />end complete 7
<br />/ ~ t /,
<br />/~ yJ
<br />O ~
<br />~ /
<br />f'
<br />,
<br />,
<br />,
<br />,
<br />.
<br />I
<br />o
<br />i
<br />th
<br />ifi
<br />al
<br />f SIGNATURE OF PRINCIPAL ED(ECUTIVE ^ r !~
<br />em aware r
<br />ere ere s
<br />gn
<br />ar
<br />rem pene
<br />ee
<br />or submitting lake information,
<br />TYPED R PRINTED OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />Inclutlin the slbil offna and im risonmem br knowln Wolellona.
<br />V UMMCN 1 5 ANU tIYLANA I I V N V h ANY VI V LA I I V NS (HeleBnCe a// aheChmeO(S here)
<br />"55 +; LO*AL I4'%`~ LI:'I'? ~LLL iii: .AIY=U, tiGl ;;ETTLCAr~LL __;.IDS LI°f?' AYF'Li:. pL:: C=iGYF,).4tin ?~,!:CI? EYLt:T-
<br />-.... I. a.~, PG 'J, F'Od riF:~~UI9FdENTS. JIL r, :'fF.A°;~ cfr~OgTIF;-SF'F I.o.1.F, i :I I. ;y'I'SLY :iA::rLI,'IG
<br />~P• orm 3/ } `ire i6us itions ay be used. T IS IS A 4-PART FORM PAGE OF
<br />00549/00071-r-1350 1
<br />
|