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<br />PERMITTEE NAME/ADDRESS (/nclude Facillry Name/Lxarion ifDi$erent)
<br />NAME '
<br />BLU° "JU'~T.1I~1 n'It.P.vY, lAJ.
<br />ADDRESSD I. 5 C c. iw U 1 I 'i f
<br />FACILITY Y" N.r L Y _ .. t~ l b u i
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMRJ
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<br />^ PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 7 7 U 1 V i TO .'i i :') J 1
<br />Form Approved.
<br />OMB No. 2040-0004
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. PREOUENC SAMPLE
<br /> EX oP TYPE
<br />PARAMETER ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICartdy under penalry of law Nat this document end all attachmenLS were
<br />i TELEPHONE DATE
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<br />prepared under my tlireclion or supeMSion in accordance with a system tles
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<br />e SIGNATURE OF PRINCIPAL EXECUTIVE ],
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<br />TYPED OR PRINTED lam aware that there are signifrant penalties for submming false inbmwaon,
<br />indutlin the ssibAi of ene antl im nsonmenl br knowin violatons. OFFICER OR AUTHORIZED AGENT ~ NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reverence al/attacnmenrs Here)
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<br />SPA F ro m 3~3~0`•7 (F'1E~13nJ9)' Previous editions may be used ,/ / I G ~ 0 U G ~ i 7HIiIS A 4-PART FORM PAGE OF
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