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PERMITTEE NAME/ADDRESS (Include Faalir)~ Nome/Gomrinn i~OBercm/ <br />NAME C'/FrU~ (A""rA '1:.LL '' _UdL (;OiF. <br />ADDRESS„IRES 1,23 ;CU'iR, 5 '~Ci:;A~' PK <br />Ylt)J i95T MI•Ith:.L :'I.tCLii <br />FACIOTYENC:L;:4QOD CJ BUISS <br />LOCATION <br />P3: 190N.HI~ K. tS:;GLEY, G`:3h'flAL ATNY <br />NA710NAL POLLUTANT DISCHARGE EDMINATION SYSTEM (NPDES) Form Approved. ,~"y { <br />DISCHARGE MONITORING REPORT (OMq; OMB No. 2040A00 ~l, <br />a.rsf nz s) t'A.IOt! <br />Approval expires 0 1-9R, . <br />rnnn» 511 nn.. e ($Liir RN) ., <br />PERMIT NUMBER DISCHARGE NUMBER F - : I ti A L ~' R,OU~It' <br />MONITORING PERIOD !§I:+E 1, POhU c TO FOIL°L C ~BEK .I <br />YEAR MO DAY YEAR MO DAY <br />FROM VU Utl U1 TO UU Utl d ~'.<'x NO DISCHA9GF. I_~ f:v <br />(zo-zal Izz-z3) lz4~z5) !zs-zr) lze~zs) (3o-3r) NOTE: Read InsVUCtions before completing this form. i <br /> (3 Cartl Onry) QUANTITY OR LOADING (4 Certl Only) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (46-53) (54-61) (3645) (46-53) (54-61) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br />69-70 <br /> lez bal (64.88) ) <br />( <br />_r'~i ^i, TU'L'AL <br />' SAMPLE <br />M <br />SURE <br />ENT '`^r,"..O X~?;:YY# r##C :# ~1 <br />~O <br />~ <br />O <br />Z <br />~~ <br />O ( 19) <br />~ <br />I/~' . <br />(AS P <br />E) EA <br />M e <br />, , o <br />o <br />1'J'JS 1 U U PERMIT rR4r atp#+§r br8l11iC~t° #CC ~i§{i431k#. 3'. PJ <br />~ I'~ ;', <br />~ O MCE/ # ~ <br />i't'LUE±1T GNOSS VRLU; REQUIREMENT ~ to ~;,yar~;~'-_ #### ;~ ~- <br />,~~*s ,'~ - <br />~,-~ '"= 11G/L MONTH _ <br />' <br />LOM,IN CO NUUIT OH <br />' SAMPLE <br />M <br />RE <br />E <br />T Dlp~ <br />CVl I)3 ( 03} ~+####~ #~~~~'~` a'r###4# O J <br />~ <br />' <br />( <br />~I <br />•':LU T`!r:AT t76?JT PLnN <br />T EASU <br />M <br />N • p <br />. <br />V <br />~VUtlU I U U <br />PERMIT <br />$'£ORT <br />'} <br />7 <br />{ " <br />;~ <br />} <br />.r <br />ba.: a <br />fA; y <br />~y <br />LY <br />' STA~i <br />:K <br />: <br />PYLOE[rT GHO55 YALU'`: ,REOUIREMEN7 31x>~il AVG ~ L ~, <br />` I <br />GD ~ <br />t';' <br />" ` ~~~ <br />` r <br />: e~;r +}#t .i ~ <br />~ „ <br />. . , C i. <br />. . <br />!1L AEID GFEA5C SAMPLE T#'#~ ~ ( 9U) ##Id##a ##X:##!~ ##a#:~# " '~ <br />1 <br /> <br />I :i J A- L <br />MEASUREMENT <br />v ytSUAL <br />~UUtb 1 D U ,"'P.ERh11T #i+##*=# p .-Y ES=1 #xrA#4tt ", ,;=-ICS!'#47t;~ .`:N+i3#~1'+It)fI.~14 4C-'; ";~:ii E$KLY ISUAL <br />r.F'E'LOt:."(T uROS5 YALUB 'P~OWIREMEN7 ~ <br />It3T 19X- <br />NO=U <br />": '~ <r=;-" <br />:-;. <br />#a## <br /> SAMPLE <br /> MEASUREMENT <br /> ~~"PERMIT ~ ~- <br /> -REQUIREMENT - ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />REQUIREMENT <br /> <br />t <br />. + r <br /> <br />' y . t., t <br />~?~. , ~- <br /> <br />3 f <br />~ - <br />~~~ ' n <br />~ <br />,~_ * <br />:: <br />r <br />` <br />, <br />: - . <br /> , <br />. ,-t s <br />: <br />~ <br />. - ~-iw <br />. :. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ - ~ - a n -. <br />~~~ <br />~ <br /> REQUIREMENT - - - ~ ~ `~ I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~. ~ " ,~ <br />NAME/TITLE PRINCIPAL IXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSONALLY E%AMINEO AND <br />ATION SUBMITTED HEREIN <br />AND BASED ON MY TELEPHONE DATE <br /> <br /> <br />I:ichard Mllls ; <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />THE INFOgMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE. ~1 <br />/~ {/ /'I <br />// <br />/ <br />/ <br />/ <br />/ <br />/~ <br />J <br />/ <br />/ <br /> <br />SJO-H7O-YJIY <br /> ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />T <br />NF <br />T <br />ON <br />U <br />TH ~ <br />( <br />L( <br />/~ <br />/ <br />,/ <br />/ <br />'// <br />!/ <br />13 Sh <br />m §C~ <br />G <br />Environmental A7anager TING FALSE I <br />ORMA <br />I <br />, INCL <br />DING <br />PENALTIES FOR SUBMI <br />E er <br />an -/ o? <br /> POSSIBILffV OF FINE AND IMPRISONMENT SEE 18 U S.C. § 1001 ANO 33 U.S.C. <br />l <br />d SIGNATURE OF PRINCIPAL EXECUTIVE <br /> utle lines up to Ef0.000 sn <br />or <br />§ 1319. (Panettres untler these sleturas mey inc OFFICER OR AUTHORIZED AGENT <br />TYPED OR PRINTED msximum imprisonment of baMeen6mamhs sntl5yeers) DE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIDLA I IONS (Heterence ail aaacnmenrs nere) <br />r.Ll':'.NA'i}. LIMITS FOd T55, IRON F. SETTLBAfiLf: SGT,IDS (LOC '0') ACPLY GNLY I? <= 10-YF, 24-H^n P%tFCIP EV°NT <br />id CLAICF:D. S?E I.A.2, PG 1H, FOH `aURD-°.N CF Pii00F R~:QUIBE.^cNTS. UiL E GREASE-SEE FGC^BCTE F/, PC• Z. <br />Epp-Frirm 3320.1 (OB-95) -Previous editions may not be used ~ ^(REPLACES EPA FORM T-4(1 WHICH MAY NOT BE USED.) 0 0 0 7 U / 0 0 0 U 0 5- 150 1 PAGE OF <br />- -- - - - - -- - --- - " - -' - -' - - - - - J --- <br />,~ <br />n <br />