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•ITT[[ NAM[JADDRUt (Inrllldr NATIONAL POLLUTANT gItC NARO[ [LIM INATION tY[TLM INPOF.!) <br />6y NanM /Lotulon 1/ dlprnnl> DISCHARGE MONITORING REPORT (DMR) <br />If ~TH~11j hAh I+AtiI(1 Vlraj wl., IF.f_ (2161 l17d91 <br />~~_ft~ 7. n+,~ hni-_-_---__------_-_ (Ilnr4n441 onl, <br />~R-jr(IIIAp PERMITNUMtER DIecHARGENUMtER <br />--(11 Rjl)n~--------------- MONITORING PERIOD <br />~~-------------------- YEAR MO DAY YEAR MO OAY <br />Form Approved <br />OMB No. 200160015 <br />- FROM h 4 .l j () 1 TO fi 4 I ~ .{ <br />T}QM ------------------- <br />• l:r u, lD rH rrl~nl ur+n ur.Jr, r.wyD NOTE: Rud InsWelbnt MID1t eO11iItIMq tllltlarnl. <br /> (J Card On1YI QUANTITY OR LOADING (1 Card Only) QUALITY OR CONCENTRATION ~R{OD[MCY <br />PARAM[T[R (16-JJ) (1161) (Jb~J) (!d-!J) (l16J) NO. Of tAMPL[ <br /> <br /> AVERAGE MA%IM UM UNITt MINIMUM AVER'AOE MA%IMUM UNITt <br /> 6161) (616!) (69.70) <br /> [AMPLE • <br />TN ~ I ~ 1 I IIr (I 1 j MEAL UREM ENT , • / • • • / • 1 A• <br /> w[Rwlr 1 ~.,Lr• . . ,. ~ ~~ :,~ . <br /> RtOY1RwRNT ' ' <br />`-~ .. " .~ <br />r ' <br /> tAMPLE <br />~I151 T;ITAI till'. 1' MEARUREMENT • •' k • • f <br />FFL111r.TI PPI/IT I L~IIq It NI•/I ,z F,; k. <br />= <br />S A R[OYIRWtMT • r r • • <br />• • • • • • • f L <br />~ ~ '' ' <br /> ~ j <br />. <br /> tAMPL[ <br />1N[TI(141 MEA[UREMENT • f• • • • i <br /> /tllMti .. <br />~i L ~ 1 If /1•A - - iLr M(~./L .4 <br />x <br />F 'i; ~Ajj..y <br />?r~j~~~F J~ _fl <br />:~~. `. <br /> R[gY1R0/RMT , <br /> tAMPLE <br />• F , L I. II <br />C MEA[UR EM EHT • • ~ • • • # f • # R • • ~iF <br /> PRMITI rr ~,~ k i.lk - ~ 911 ~"~ "~ <br />~ ~ ~~ :9i .T~8 <br />~ <br /> R[OYIR4/[MT ~ -d' ., -j , <br />.. i'~. .r 5 .m <br /> ~ <br /> e <br /> tAMPLE <br />• k (ykF A •~ I MEARU REM ENT • • i A • • • • • <br />SIIAL PpIMiT _~ <br />~ <br />f 1• MG/[ '~ , ~ >. .-3 <br />D07 R[QYIRwWT • # • • • • • • • • # •.# • • <br />Y <br />' 'I ~ .,;.;~ •• ~' <br /> tAMPLE ~ <br /> MEA[UREMENT j <br /> <br /> <br /> <br /> tAMPLE ' <br /> MEA6UREMENT <br /> <br />" <br />~ . y <br />: <br />° t rn <br />- <br /> KIIMIT . <br />- L <br />~ a. r . <br /> R[4YMWtNT .~ ,~,,. , <br />[/T TLE IR INCIPAL [%[CUTIV[ OFFICER I CERTIrY UNDER,PENALTY OF LAW THAT I HAVE PERSONALLY [%AMIRED <br />AND AM FAMILIM'MTH THE IMFORMATOM wWITr[O HEREIN <br />AMD Yfi[D TELEPNON[ D A T [ <br />C Q . <br />d1 MV INQUIRY DF TIgrE INdVId1AL5 IMMEdATELY RE6PONSIfiLE FOR , <br />G. [R OHfAINING THE WfpiMATgN I IELIEVE TH[ $116WTTE0 INFORMATRIN <br /> I6 TRUE. ACCURATE AND COMPLETE I AM AWAPE THAT THERE ARE SIG <br /> KICANT PEMALT $ FOR $URIITTNG FALSE INipIMAT10f1 INCLDOMG <br /> THE POSSIfi1LTr ~ FINE AND IMPR6pNMCNi SEE IB U$.C 1 Id)I AND <br />3J U$C I1J1• l~iil•Ilirr wdn IArr rb(uRr nMY mdvdr /mu W b ZIO <br />OPO fIGN ATURE OF PRINCIPAL E%ECUTIVE <br />• <br />i Y-[D OR PRINT[D , <br />nM'Vr m~:,mMn~ menlWMbxn6montAr •nd 3Ywrr1 OFFICER OR AUTHORIZED AGENT MUM^!R Y[AR MO DAY <br />ILNT AND E%-LANATIO11 OI ANY YIOLATION^ IAgnmor PRA anuanmrnu noq <br />P111 I)~i[HOB1.( .1(.(11PF.f II 11111. (11G T11),i k( /'i1x71 II 7. V{ 1l~i.ll~ I)11'llirT t~(II Ol'.'i( hll,Mf..F• <br />• ~,~lsUlAR17s_ 1 1 <br />rm 77ZO•I (Rev. IO•J9) PREVIOUS EDITION TO BE U6ED IREPLACE9 EPA FORM T-•O WHICH MAY NOT BE U6Ep.1 PAGE OF <br />UNTIL 6UPPLY I6 E%NA U6TED <br />I <br />IAN <br />r <br />a <br />IMw <br />I <br />- I <br />i I <br />~ rrI <br />~~n <br />rl <br />rr~ <br />