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PERMRTEE NAME/ADDRESS pMJr£sWryXer/Lormla I/D~i.w) <br />NAME <br />ADDRESS ~r .. -.- ~ - ~ <br />FACILITY ~ <br />LOCATION ~' - ~ ~ ~ ~ ~ -~ - <br />MATIONK POLLUTANT DISCHAPOE ELIMINATION SYSTEM /NPDESI Forrn Approved. <br />DISCHARGE MON170RIN0 REPORT /DMR1 , , O/~IB. No. 2040-0004 <br />IP-I61 17-I91 ~ - ~ - <br />- ~ 2 . I ~ ~ \ I Approval exgiree 05-31-~8 <br />PERMIT NUMBER DISCHMOE NUMBER ` _ ~, / F <br />' ~ ~ ~ ~ MONITORING PERIOD i <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ I ~ ~ -.~ TO ~..; ., -, , ~ __ I ., . .. <br />c /161!/ !ZZ-Z3/ lT415/ I1677I /2a-1s1 13a3n NOTE: Read IrutruetloTr bNwl ComPletiny UTw form. <br />PARAMETER !3 Grd Ontyl QUANTITY OR LOADING !4 Grd Ontyl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> l16-531 154-61/ I-TB-<5/ /46.531 154611 of <br />l31-371 EX ANKV515 TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS na.sai 16.4681 16x701 <br /> <br />. SAMPLE I ~ <br />~ <br />t 71 <br /> MEASUREMENT `j ~~ 5 ~ ~ ~ ~~ / ~~ ~ ~ ~ '~ <br />~ <br />~_ :) . <br />:. f L I' <br />. PERMIT r n ~ cti .-, <br />!; -/ r, :.. , <br />: J d is L _ <br />~ ~ _ <br />`) ' ~, <br />: '~ ', <br />.1 <br />~ <br />- <br /> REQUIREMENT . . . <br /> 17 ~1'. 1 5i:• I (• 9:.~ <br /> SAMPLE <br /> MEASUREMENT <br />~D <br />'~ECG1 V <br /> REQUIREMENT <br />0 g 1999 <br />~~~ MEASUREMENT <br />~ ~~~~~ PERMIT <br />;l winela~ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> 'REQUIREMENT <br />~~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . <br /> REQUIREMENT <br />i <br />NAME/TITLE PRINCIPAL EXECUTNE OFFlCER I CERTIFY UNDER PENKTY OF <br />AM FAMILIM M11TN THE INFO UW THAT I NAVE PERSONALLY E%AMINEp /WD <br />RMATION SUBMITTED MERDM <br />AND BASED ON ~ <br />~ <br />TELEPHONE <br />DATE <br />I<~ t' I ~ ~~ c l;7 F_ l ; <br />MY IMQURY OF THOSE INDINDUKS IMMEOIAT0.Y RESPONSIBLE FOR - ~ % <br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION le ~/ <br /> <br />i _ TRUE, ACCUMTE AND COMPLETE. I AM AWME THAT TNE11E ARE <br />90NIRCANT PENKTIES FOR SUBMITTING fKSE INFORMATION <br />INCLUDING <br />-- ~ " ~ <br />~ - ' (~ - ~ I • " <br /> <br />I ~ <br />~ ' I ~ , <br />THE POSSIBNTY OF RNE AND IMP1eSONMENT <br />SEE IB U <br />S <br />C <br />11001 MID 71 <br />%~ %/ ~ _ <br />r~ = <br />~- <br />. . <br />. <br />. <br />. <br />u <br />s <br />f T7tB <br />q <br />eB <br />c <br />p <br />e <br />a <br />N <br />a <br />w <br />! <br />D <br />BIONATURE OF PRINCIPAL EXECUTNE ~ ~ r <br /> <br />TYPED OR PRINTED . <br />. <br />. I <br />.. <br />. <br />.. ur <br />nw m <br />c <br />o <br />rt.. nut <br />dr <br />l.. w ro <br />r <br />,DOO <br />ArM wmvlnnl J+lAdmnwrrNbMwntmmWAM6/rrU <br />OFFlCER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAV <br />GOMMtN I o Nnu cnrtwnn I wn yr nn r vwuA I rvno IrtBrwencs an errscnmsnrs nets/ <br />EPA Form 3320.1 108-851 Previous editions may bs used. IREPLACEB EPA FORM T-00 WHICH MAY NOT BE USED.) _ PAGE OF <br />.. / ~ - ' <br />