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PERMITTEE.NAME/ADDRESS (Include Faci/irv Name/Locatlon ifDifferenr) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) ~ Form AFIPfOVed. <br /> NAME T ~ e P P e Y ~+' 1. V I ,r G ~ I ti C. DISCHARGE MONITORING REPORT (DMA) - - ~ OMB N0. 2040-0004 <br />'1INOR <br /> ADDRESST RAP4ER "1SNF: r <br />~ 5 U 3 3 N Y) <br /> P. 0., . B J k 1 :~ "~ PERMIT NUMBER DISCHARGE NUMBER <br />F - FINAL lIOFAT <br />' FACILITYC~~IC' CJ 51626 ~ - MONITORING PERIOD POND T0~ 4EST PYE1~T! GULCg ' <br /> LOCATION ~ YEAR MO DAY ~ YEAR MO DAY <br /> FROM D 10 0 ~ r0 0 <br />- ;~aa NO DISCNII:ROE~ $aa <br />" <br /> ATTN: 4l. GOkUCI",I PcT345 PR$5/GEM 19GR Plelnylhisform. <br />~ NOTE: Readlnstrucponsbefo <br /> • ~ QUANTITY OR LOADING QUANTITY OR CONCENTRATION .NO; FREOUF,IJC <br />~ .. SAMPLE <br /> PARAMETER - ! -'EX ~", OF., TYPE <br /> ' - AVERAGE. :MAXIMUM <br />• UNITS - MINIMUM AVERAGE MAXIMUM .~ ~~UNITS; AN'at'S/s <br /> Pit ~ ~ SAMPLE On#A1lta .~ <br />Raa#a~a a##aa# .~ ( 123'. ~- <br /> " MEASUREMENT ~ ~ ~ .. <br /> 1 <br />J1DD 1 U U #~~ i :Y <br /> dFFLUEtJT GROSS YALU' *" "`' • <br /> 04LD5: TOTAL <br />: ~ ~ ~, a <br />" # 't <br />'. •k' <br /> ,M <br />.USPENDRD~ 4r,; t5 t <br /> " <br /> <br />~ <br />EFFLUE,N ZROSS YALU <br />qd'b <br />r'" r <br />~, <br />, <br /> SOLIDS, SET?LcAB~' PLE <br /> <br />' "'"iaaa4 .#Rtnt #aa+QR • <br />F' 253 <br /> f r°~e <br />REMENT ~ <br /> ._ a <br /> <br />~:; _ <br /> <br />, .4: i <br />.' ~ <br />~ <br />f <br /> RON~ TOTAL'•',.. L.' SAMPLE i'a';':4k aaa# 041pr <br />{'~ 19) <br />i ~ ~ : ~ A j F ej MFjt5UREMENT fj, .a" ~ ; <br /> loos 1 D , b',• ~• <br />' <br />' <br />~ _ ~5 <br />s ~a <br />.,D~ <br />HFFLUEA`t :&R t aM Syr;; "+~ : ;~ ~{, <br />'' )ZL A~'~G.i~'"" ~ r:" '":SAMPLE <br />c i•,~. . <br />~ 'xaaaaa ~• ";^":"#F¢Ib#Od +bR~R~IOf"' ~ 193, <br /> , rr <br />MEASUREMENT .~ ' . ~:. ~ ' - ,P <br /> ~~az ~ bRa ' <br /> r'FF'LUEl1 9 TALUS ~I,'" `' ~,;, #aa. <br /> •LJii. ;~ DUIT UR SAMPLE ( D3)" aaaa## aaaaaa Lr Atr^• <br /> TNItU ~~ ~t:dT PLANTMEASUREMENT `' ' - <br /> T <br /> 'iN55 VALUE ~ ~F GO..~ <br />FFLU : #sa <br /> 31TAL SAMPLE na$¢aa #aaas# ##b#R# <br />~OLID9~ ~. 1'9 )' <br /> a . <br />I S S O G~ MEASUREMENT , <br /> ] U19> ,~;, ;,:.0 U as r' . <br /> FFLU ' RO55 YALU #aa ". <br /> NAME/TJ faPiUNCIPAL EXECUTIVE OFFICER ICertHy untler penalry of law that is document'and'all enachmerMS were . _ TELEPHONE 'DATE <br /> <br /> <br />- _ <br />_ praparetl under diretlio~ oof s ervi if on In accordance Y$hgFy°'~ der °:goed __ --- - - - - - - - - <br />--'~- -- - --'- - -Io essv~qu i e ersonriel~propedy gather, antl e~,a;uate tnA inlortnation ~~~/ .'y '~ is <br />submmed: <br />BasetloRmyinWirY'cl fha Person oCPBrsons who mNUgatnasystem <br />GOEI~eh ~Fat~ro . <br />~+~ .11~ <br />w <br />" '70-~$2~-w <br />61 D} ~ D <br /> . <br />, <br />. <br />. <br />' ~. <br />i <br />l 16 <br /> pn <br />PteeidlatfGnaraL Mau ar or those personsdireNy responY~ble for gathering the imormation,lh9 nlormayy <br />~I b <br />la <br />b <br />tlf <br />iha b <br />t 6k <br />lm <br />ed <br />l <br />t <br />t <br />e <br />• <br />~ <br />t <br />~ <br /> o <br />u <br />m <br />e <br />tly <br />gp and belie <br />, <br />me, accura <br />te. <br />as <br />owl <br />e, ef <br />compl <br />a, <br />~ SIGNATURE OF PRINCIPAL EXECUTIVE <br />' <br />U <br /> ~- .'YYPED OR'PRINTEO ,l am awarpjhat rhete'are g)gnirtcar%penalties for submiT.ingtaseimonriatiGn, - OFFICER <br />dudin 'A osslbJi olllna andi ris~ ment br6nowin violadore. QR AUTHORU:ED AGENT <br />N <br />MBER YEAR MO -DAY <br /> COMMENTS AtJDEXPLANATION OF ANY VIOLX{TIONS (Reference all attachments h@re) :, ~ ~ ~• - _ ; <br /> TS5 °. T~11T;L SIIO#~LI'BITS YILL BE WAIVED, A"ND SESTLEABLB SOLYDS LINIT ABPLIBD FOR "<=16I~1~`~gflR.p$$Cip EYENT- <br /> SEE BURDEN O.P PRgOF''REOOIRE7ENT5 UNDER I. A. 3. TD5 !lOMITORING - I:B.3. OIL E GREASE -' $E6~ .X'.6i+1. (D) . <br /> A orm 33 : 9) (evlo s e i Ion may r. < "~. ' „- _ _ _- _ _ ~ THIS I$ A g•PART FORM PAGF nP <br />