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PEPMffIEE NAME/ADDRESS Q,uira,FxWryNaw,/La,nm UDI$.ou)
<br />NAME LNLItuY FJiti l.S ".r14i5:: ,: ;jti?A`.1 'i
<br />ADDRESS d A'C G ti ;: i7 ~' !' +: h I iJ E
<br />35U INDL9•,: SI'iiF.°:i", iUI't'F: IUD
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<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELMINATON 6VSTEM (NPOE$)
<br />DISCHARGE MONRORINO REPORT OMRI
<br />Z-I6l 17-191
<br />::JGH50032 uv
<br />PERMIT NUMBER DISCNAl10E NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAY
<br />FROM i TO U' iiv j ;
<br />' rzmn nzasr /94JA'1 l26Z71 n8-191 !34311
<br />Form Approved.
<br />' ' i. * i ~ ..-,. r. OMQ Noy$040-0004
<br />Approval e~ife~ 05-31
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<br />- ~ NOTE: Reed Inetrucilom belors compleilnp this form.
<br />PARAMETER !3 Cerd Onryl QUANTITY OR LOADING /4 Grd Onryl QUANTITY OR CONCENTRATION ND. FREQUENCY SAMPLE
<br /> 14653 15461 38-06 14663 164611
<br />EX OF
<br />TYPE
<br />(3Z-371 ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINI
<br />UM AVERAGE MAXIMUM UNITS ntz-sal !64681 163701
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<br />~OLiG~, SETPLF'Ar~LL SAMPLE ... .:: :c ...... . G#K•rar;: ... .. ( 25) ,.r
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<br />MEASUREMENT
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<br />IL AfiU '::,{EASE SAMPLE .,O a+t S=rt 3aG.
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<br />3SU2 1 U U PERMIT :.>'fdi~nx :rata,~ary ;:r,,; ':titf$iFK1~.r +~>~+.:~ = iJ ,~,.."TI,`r' ?iA3
<br />F'E'LUt'Y'T Gi?;SS:i VALUf. REQUIREMENT ;:#GR
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<br />"LOk, It: :, DNOUIT J[i SAMPLE ( D3) ''`%'Cr 7%#+ :: ,~:;: .:, : ;::y::: :; r.,
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<br />UU`.iU 1 U U PERMIT ' ShTI;1k R•L' ft F:POI;T ~`~3~''^~' 'i~: £;/ H:; T;, :+
<br />'F'e'LUEN1' GkJSS Y&LUE REQWREMENT 3:UDA•+YiC flALLT MX> HGD 'JliTy
<br />iL mill GkcP-SF. SAMPLE Grtkk:"= ( g'1) aarFr:~~: ,,,. .. ..:... ,
<br />I:i U d L MEASUREMENT ~ ~ ~ f ~ ~ vl .i'' ~' `~ `-' I
<br />7VUC.0 L 0 J PERMIT ;::r-;c,-g<C:;;, HE.i?,3AT' Y ES=1 ;;t~7~+~•~k. ;fi_r~r,;~.,;: .: N;'E/ I`7;t.
<br />• c•RLUENT ::HJS ; VALUE REQVIREMENT
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<br />NnmE/TRLE PRINCIPAL EXECUTNE OFFICER I CERTI FY unow PENALTr of uw TNAT I NAVE PERSONAIIV EXAMINED AND
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<br />TTED NERDN
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<br />SUBM TELEPHONE DATE
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<br />AM FAMILIM WITH THE IN
<br />ORMA
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<br />MV INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
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<br />- ' OBTAINING TNF INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br />~ I AM AWARE TNAT THERE ME
<br />TRUE, ACCUMTE AND COMPLETE.
<br />INCLUDING ~
<br />TTING FAIRE INFORMATION
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<br />SIGNIFICANT PENALTIES FOR SU
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<br />r :~ ~. , , ~ ,c:.t :t' THE POSSIBILITY OF RNE AND IMPNSONMENT. SEE 1B U.S.C. ! 7001 AND aJ g10NATURE OF P111NgPAL EXECUTNE '
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<br />- O.s.c. ! rate. m.,rd.. ,.M.r d„r mnm,,R,r Ir,aY,e, IiN, w ro alooso AREA
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<br />TYPED OR PRINTED
<br />r,eamul,R,ni,rFrlawmnt olerrw,n en,mtlu rd 6rra/
<br />OFFlCER OR AUTHORIZED AGENT
<br />CODE NUMBER YEAR MO DAV
<br />COMMENTS AND EXPLANATION OF ANY VIDLAI TUNS IFreterencs sn eRecnmenrs oars/
<br />3tT:TLEA9LE:5U.LIJ3 LIMIT' AAIVI:U FUd LD-Ya, 24-Nk PR'DCIP EYF.NL' ~UuJcf:i l'~ t+U~:U'ti .;,'JnP ';!:'_Ul r::'tE';?'t; !b
<br />PAn'1' I.Ci.l.l?, i'. b. .il'J8"i+dTEk "4N4;:Eic:81' PLAti GUE 1-L-3J.
<br />EPA form 3320-1 108.95) Previous editions mey be used. (REPLACES EPA FORM T40 WHICH MAV NOT BE USED.1 .J . ~ , 7 , , ; I~ PAGE + OF `--
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