|
4141' E
<br />PERMITIEE NAMEIADDRESS BrrL FsWhNa//ocauan iJDl~c.elD
<br />NAME
<br />ADDRESS ,.,1: j: t~,l 1 r F:;i w'r'. Yiv..~
<br />LOCATION
<br />' 7 Ic .1-
<br />NATIONAL POLLUTANT OISCHMOE ELIMINATION SYSTEM~ 1'ir~irti/
<br />DISCHARGE MONITORING REPORT (OMR1
<br />1-161 I7-181
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ) - ~;" ,)+ TO '1 •" 7 ~. j _.
<br />!26111 l11-13/ !1415/ /16171 118-191 !36311
<br />Forth Approves.
<br />I '~ a j J,7, ~ ~-, ~ ~ Apl~dlo. 2040F000.4. ``i
<br />(j I ~ - ~ r 1 C) ~ ~ 'Approv6l Dnpi~es OS-37-96
<br />r f ai v!. l
<br />_ r .~ .. ~
<br />NOTE: Rud IfrvucTlolr Mfon cSfi-ipls<Inp~This form.
<br />PARAMETER 13 Grd OnlY1 QUANTITY OR LOADING !t a/d Onry! QUANTITYT OR CONCENTRATION NO, r~+EDUENCr SAMPLE
<br /> 14653/ 51-61 38-5 1663 5461 of
<br />l31-37/ EX
<br />ANA
<br />rss TYPE
<br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !6S-a91 a
<br />(64881 l59-)Ol
<br /> SAMPLE .::;- {: t: [:': :+ ~ F r,; :!: ;c .. .::.:e r: '. ( 1 + )
<br /> MEASUREMENT
<br />.,. I'' C .~ .. PERMIT. ~.
<br />...
<br />~•~#.'»
<br />~ 4rtt-'.°.~~=fi ~.
<br />
<br />~
<br />~
<br />
<br />
<br />..
<br />:'.c F,~, S~ ..
<br />
<br />~ S~t ;~~.±1.'a.~ il.ti .... EC:,
<br />
<br />- .~:~I.
<br />
<br />
<br />
<br />•
<br />'
<br />:. ~ ~ - ~ REQUIREMENT ~ ~
<br />~ ~ :A; -
<br />.~. N,:i Y~." mil l4:..
<br />i?.., r.)T1L SAMPLE :.k: t: [: : r: :..:._.. ...xp•-:.
<br />~'-~ ( 1
<br />~)
<br /> MEASUREMENT
<br />
<br />..1v L r. i> PERMIT ~:~ -==?6ti+7A~x`~: CFId3~~Fl4r'a r;:0 ,~.14~~yf~1.~#~:i~: .: i'i~ ~•:~`a}~(rr~C:~:,~.:.~.:.,:' ..: (?~NW?/ ~~~1,}1
<br />.... ~ ~ , ,. :REQUIREMENT
<br />
<br />~ ~ .. ~ G _, 4{: .. .. T
<br />
<br />r
<br />~. ?
<br />•.~L{.US, _,.~.?TLEP•L:• SAMPLE ....:t ~:,a:rq-<: r::.r.
<br />'"k .-. (
<br />'S1
<br /> MEASUREMENT
<br />I.:II S C .) PERMIT .~~ O#ir >;<is fk
<br />..~.. >t1k?31_'AiX.i G;: :: ..:..~.". 1t~L.=1PC& ~ ~.:3~p.~'I.. ~}1A1... .t~.~~~~;~.;.. ~.:: :~ ~ !?'i~~~ ~~AG
<br />:. t'}'LUe.I .' /:-" Yl;LR _EQUIREMENT~~ ::~:L;::.:.,.
<br />.;' ~ «0.. ;. ~ ~ ~~.
<br />_ ~'. F i•-.: '., SAMPLE C
<br />[cis :: p k:xn ~::} .. .. ( ) ~%)
<br />( T-) MEASUREMENT '
<br />. L~„1, „ .1 '~:'.,~ERM17
<br />~`~~ t,.K+~p~S'x::. ::c=Se',:~re;= .+T
<br />~ ~~ Q~:`t.^.(:r~rf 1~,~ T,,7... E'; i."./ 'RA®~
<br />', [. ;• }'. `_i YAL(I
<br />y EC! IREMENT ~ ~
<br />~ t
<br />•: rn ~ ~ >~, ~r T: ...f
<br />,.': r, ~. ,7i°L
<br />..L~ SAMPLE .'::;/;: L:;:F Y ;:~~:-~ '.ECI'::.- :~<c9 `i+ ( 7)
<br /> MEASUREMENT
<br /> :. ,.
<br /> EQUIRENIENT'
<br />.. , I'I ,LOYrlli ~
<br />'1' ~+ :: A : Y N ; SAMPLE
<br />EASUREMENT ( ?_i) .'.c:kAL::
<br />•- ..:tnk.e.; ".:ya;;{:rtr
<br />1 (+ f
<br />~~_~ ~ . .PERMIT
<br />R£FQRT"
<br />:... RI:P
<br />QRT
<br />[i+s+.Tp;s; .
<br />~
<br />. D,:::1s0e~.:
<br />: ::z~k,r•:~
<br />.•_,;...
<br />u;,,~l
<br />:v-r'
<br />.r i:,'.1ENT GHpS° " ~ EQUIREINENT -i QL?A 3VC:~ t
<br />~.. .L1~AI N.~ Mj "GD ~ ~ .. ....
<br />JiTJ5, TJ"i AL SAMPLE ..+.="•O ~.`- r6d: c:^:y :+i: ,i#'=: ~ 1 ~)
<br />LS~~)LY LD MEASUREMENT / /!~ ~
<br />I J ~ i S 1 C `. .PERMIT ;;cYjTJ~::uA : :k'~Tk1,TFY:-k ... C715X#fi:• is ~ ^r, L .t = 1. ,
<br />i' +' L 116 :T .^. :: F O Y ~ " .'.:. n EQUIREMEN7 .. , ...'. et ^ •
<br />~ T a., .A Y ;,: .~ / !.
<br />NAME/TITLE PRINCIPAL EXECUTNE OPFlCER I CERTI
<br />AM FA Fr UNDEiI PENALTY OF UW THAT 1 HAVE PERSONALLY E%AMINED AND
<br />MILIAR V/1T/1 THE INF0IUTATION BE1eMITTED HFRDN; AND BASED ON / -
<br />I TELEPHONE DATE
<br />_
<br />//
<br />I
<br />J ' ~
<br />) 9 MY INDUIRY OF THOSE IMOIVIOUAlS IMMEDIATELY RESPONSIBLE FOR
<br />,
<br />,
<br />''
<br />•v(! ~I II(~l / / )~i ! J k ~ OBTNNING THE INFORMATION
<br />I BELIEVE THE SUBMITTED INFORMATION IB ~ ~
<br />~ ~'
<br />1
<br />I /
<br />l
<br />~ ,
<br />TRUE. ACCUMTE AND COMPLETE. 1 AM AWARE THAI THERE ARE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATON
<br />INCLUDIHO .
<br />.
<br />/ i /~,,'//~
<br />/
<br />(/~ ~ (/~
<br />).`~l(/ ; I I , / / / ,
<br />THE POSSIBILITY OF RME AND IMF'WSONMENT. SEf IS U.S.C. ! 1001 AND 9J
<br />/}yYIIA+. WI/II MM /YdIFF vM
<br />U
<br />S
<br />C
<br />! 1915
<br />IncAN. IMA
<br />N iI0
<br />000
<br />SIDNATURE Of PRINCIPAL E%ECUTNE
<br />~~ n
<br />'^ ~ % / ~
<br />/
<br />/'
<br />''
<br />E .
<br />.
<br />.
<br />.
<br />Y
<br />,
<br />W
<br />ti
<br />{
<br />I
<br />b
<br />N
<br />6
<br />TYPED OR PRINT
<br />D MCCI nMF
<br />IYII
<br />TIY
<br />YIMIYIT O/
<br />fM.vn engn
<br />. ~Id
<br />YFrR/ OFFICER OR AUTNORQED AGENT COU NUMEIER YEAR MO DAV
<br />L.VMMCINID MrYU CAIlA1rN I IV+R Vr Air+ rlvLn I Ivn~ Inv,msnGV p, eueunnvns nqv/
<br />. , ~ _ . T . - T T ,
<br />EPA ~ ~m 33 O- IO~r- Previous editions mey be uee iREP CES EPA FO T+l M Y I OT USE ... - / _ PAGE pp
<br />'f
<br />
|