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PERMITTEE NAME/ADDRESS (lulude Paclliry Name/Loco(ion ijDgerenq <br />NAME - ., <br /> <br />e,: _ <br />.. - o <br />ADDRESSIp'IY' ?-r"9 ''J1..~ <br />i n ; ~ T . _ '. .- ._ : <br />4 L I <br />. <br />, - - " W <br />FACILITY ~ <br />LOCATION V ~ <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESJ <br />DISCHARGE MONITORING REPORT (DMR~ <br />(3ae1 !n- 91 <br />'x 1l 7T ~ ^ nn+ <br />' PERMIT NUMBER DISCHARGE NUMBER <br />~ MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />F~M :l ~', 1'. TO '": ~: •f~ It <br />(10.Pi1 (az-z31 (Z4-251 !~&2]I rt&TB) (30.31) <br />Form Approved. <br />OMB No. 2040-0004 <br />' ' .• Approval e~ires 05-31-98 <br />/ .~ NOTE: Read Instructions beforemmpleting this form. <br /> (3 Card ) OQl?1TITY~RLOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (4653) (54-Bi) (38<5) (4653) (54-81 p( OF TYPE <br />(~~/) AVERAGE ~IA%IMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~Le 13 69-70 <br /> lyz4nl <br />.f":~u~~: Jf"• SAMPLE <br />MEASUREMENT rx ..~:: ;:. ~.ttx k.. <br />~O3 <br />~0~~ <br />( , tl <br />~ <br />~ ~~ y~O Q <br />OF ~r/ <br />"_. i; r)u 1 J :' PERMIT ?3911 F#. geR4#.,~#" ~ :*'3 #+~#.lcR# K~S <br />/ ?tPpflBT '9 "v(l/ ~' ~~ j~1 ~~:.. <br />~X <br />.'L'J=:"T "'17'i 'rf i ~'= REQUIREMENT wt.;: t <br />' #43~ *^ ilT rr q! , <br />- <br /> SAMPLE <br />MEASUREMENT ,:r;:.x3a 2xF:3 <br />r <br />~( ~3 y.3#,.. <br />, ` ( 1?~ ( I <br />O ` 3 <br />T 1 <br />f~l1 r <br />.,h~]'I ] 7 ~ PERMIT 'e'xk3:Sgr ,'_ #~1(, @ *~:r: ,~~~ ~; .~~.. ~ a?d'~ <br />v~ <br />,t;'; r~ <br />~.. <br />~+( <br />... 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"'=:= Wridr;cit014ti <br />;; ffiEAb~7C <br /> <br />,. <br />.mot ~ <br />~ <br />$CR/.. '^' <br />•8A "6 <br />CO'+'IEY!'S 'T.' REQUIREMENT ~ <~ '~ Ti', it ` uT /. ~~° <br />-DLI~ i~ `i~'.r'r.t'„ SAMPLE ''t:':.~t.~ 33rd:t,. ^:n•_+.....~ ~ 11 <br />~O ' 1 ( 7C) <br />Q 3 <br />~1 <br /> MEASUREMENT <br />:.t°S IS 1 '? i PERMIT C###Z~ Rktr+fM+~ O .^". ~ R+6r#'-0rtt3" RRL~OP.T RRDgR4 2 ~9P.F,/ Rlig. y~ <br />.~ I J ~~ 47 '~ ~5 ~; , • ~ REQUIREMENT -r,.~~ A Y' <br />T <br />T' ~. r er <br /> <br />~'. [:?°: %. '-.. <br />SAMPLE <br />.. <br />!~r,:~r•-r: <br />:t.,.,.,. ,. ,. `` <br />,, <br />//~~ <br />( ^' /I''/^~ <br />A AA '' <br />~ <br /> MEASUREMENT N!'T Nn Jv IV <br />--~~'~'7 L f' '_' PERMIT R3ArCGar a3#C#~S' # r-:••: #3#S r'X +X;e"S 1R## 7 tm tiT t?1' "A'AI'"~ <br />, <br />~, '!FVT ~- "1i, f;' REQUIREMENT ;~~;-~ T rr w ;~r. r rs . <br />NAME/TITLE PRINCIPAL E%ECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />RH THE INFORM LAW THAT I HAVE PERSO <br />ATI <br />BMITTED HER NALLY E%AMINED AND <br />EIN <br />AND BASED ON MV A TELEPHONE DATE <br /> <br /> <br />I <br />%~' <br />~i ~ <br />I <br />~ AM FAMILIAR W <br />INQUIRY OF THOSE INDNIDUAL ; <br />ON SU <br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />RMATION I ~ , <br />~/~~~~ <br />. <br />: <br />: Y <br />I <br />: THE INFORMATON, I BELIEV <br />~ <br />~ <br />O <br />P S TRUE, <br />E THE SUBMITTED INFO <br />D <br />E <br />C <br />~ <br />~ <br />E <br />C t" <br />i <br />9 / O L <br />7O-~ 7 ~ 2 <br />U <br />~ LI <br />J S <br />- r <br />' M <br />ITfIN <br />PENALTES <br />OR <br />SUB <br />POSSIBILRV OF FINE AND IMPR N ORMATION <br />W <br />LU <br />ING <br />T <br />H <br />E <br />G FALS <br />ISONMEM. SEE 1B U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL E%ECUfIVE , <br /> <br />TYPED OR PRINTED § 1319. (Pen9tt/av under Nose smnrtas n,ay Include linai up ro ff0,000 and a <br />maximum impdsonmenf of benaenemonlhceMSyms.) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />OV MMCN 1.7" ANU CAYLAIVA I IV N V Y FW T V I VLA 11 VNJ (F(BIBTBRCB 8119aaCIITBIIIS RB/eJ <br />.3.. .~5A':" f,I•Ir•. ~~. ~.. --~ "T.°a 11' 7(.Tn, '- ~r .r• f •' A~n• ~.. .~ _ r -I~ .. -. .. _,.^"' _ <br />^r a;5E4• `•1•": r•'• 1r I' L'+.~ Fi'I rt f!T!T i'1' lP f''j'lOP R:(x(II ]'r.^\T^~ .1 re ..n"7? __.°r onrtT V~1^:'T: ~/ D^ ~- <br />EPA Form 3320.1 (08~95) Previous editions may not be used. (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.) n N 9 q / ~ ~ ^ q t ' _ 1 ~ , , PAGE I OF <br />