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PERMITfEE NAME/ADDRESS pnchde Facility Name/Location ljihfferenq <br />NAME 3~i -. ':i .i :-CC.:.' ,..'~.~e i r <br />ADDRESS .. ~ .t r, - i 1 . <br />FACILITY ~~ ^~ t ) ~ ~ <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EDMINATION SYSTEM (NPDES) Form AppfOVed. <br />DISCHARGE MONITORING REPORT (OMR _ _ OMB NO. 2040-0004 <br />PERMIT NUMBER DISCHARGE NUMBER - - y <br />MONITORING PERIOD -- ~ • ~ - ~ ~ ~ - ~ t ~ . L ..- ~ - _ - - . <br />YEAR MO DAV YEAR MO DAV <br />FROM r ~ "i TO ^-.. 9-. ... .. . t .::. <br />r9 1 n I A) .n" ~' n 1 D ~ A /, T.f NOTE: Read Instructions before'CDFripleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. EREOUENC SAMPLE <br />PARAMET EX of TYPE <br />ER AVERAGE MAXIMUM UNffS MINIMUM AVERAGE MAXIMUM UNITS /tNALy5/5 <br />_ - ..- SAMPLE , ( ) ~ ~ :..:: .:. :.. <br />,~,;~ MEASUREMENT <br />', :' . ~. i L' .. PERMIT .._ . _ . . - _ ;, :.: ~~ ~. <br />• - ~ . U - REQUIREMENT , ~ - - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMfi <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER ICeniy untler penalty Nlaw that lots document end all attachmerns were <br />d <br />d <br />tli <br />tl <br />i <br />ith <br />i <br />i <br />d <br />tl <br />l <br />d -.,/ TELEPHONE DATE <br /> <br />: <br />)~ ,/ <br />/"r1 <br />r7 ~ - I `~- prepare <br />un <br />er ary <br />rec <br />on or superv <br />s <br />n accor <br />ance w <br />a system <br />on <br />es <br />gne <br />to essum Net queFfied personrrel propetly gaNer antl evaluate the information l% A <br />./~ ~ <br />e <br />. <br />. <br />. eubmltled. Based on my Inquiry of We parson or persons who meroge the system, <br />a dwse persoru dlreclly rasponslble for gathering the inloimetlon <br />the Inbnnazion C ~ • <br />1 G 7 U ~(i) f <br />l . 1 L~) <br />( <br />7 ~ <br />(~ ~+ <br />(] <br />• r I; t r~G • . J ~_ _'--2 , <br />submmed b , b the bast of my knowledge end belief, true. accurate, and complete. <br />l SIGNATURE OF PRINCIPAL EXECUTIVE (/ . <br /> <br />TYPED OR PRINTED am aware that there ere signifirarn penaldes for submining false inbrmehon, <br />includin the ossibTi W Bne and im dsonment far knowin Noleaons. OFFICER OR AUTHORIZED AGENT AR <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY wQLA I IONS Oteterence an atrecnments here) <br />EPA'For'rn 33267 (REtl'3/99) Previous editlons'may be tisi3d. ' ' - ~ - ~ - ~ - ~ - ~ ~ ~ _ ~' ~ THIS IS A 4-PART FdRIuT~ -PAGE ; ° •OF~ <br />