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PERMITiEE NAME/ADDRESS /lrrrlude NP.TION ^L POLLUTANT DISCHARGE ELIMIN GTION SYSTEM /NPDES ) <br />FariliD' Name/Lararion i! dill'crrnU__ - DISCHARGE MONITORING REPORT I DAfR ) <br />NAME _. -r .. Jr~kGt lr,/.!G ('-IA/ (li-l9) <br />ADDRESS'_F~ ".i MTS---~'-~---- -----_ ;'nG31 1, r1. O(; 1RC 4,,,M <br />__-___ 'T I.13 S. VITf~~~tZ~J PERMIT NUMBER <br />----------------'-------- MONITORING PERIOD <br />FACILITY <br />--------/~------------ YEAR M DAY YEAR MO DAY <br />LOCATION '~ ~ M GU ~r FROM ~ ~ a L TO T ~! ~ <br />'. I ' ti : ?•k!:~"!~t'~" , ''• v - 13 ^ W . Y N `; +.~ P ^ . - - (,U-71) r-'-'-'V Ca-751 !?b-171 r!5=91 r!o :rn <br />i <br />T^I^ I pr•p ` C fl~ <br />-~ n. ~+ •~ y. F'c.P t ora <br />~Snav, 'r~ Form Approved. 1'' US ' <br />F- r I •; ~ L OMB No. 2040-0004 <br />•' r •; p q Approval expires 10-31-94 <br />NOTE: Read instructions before completing this form. <br /> i (J Card OIIIJ') QUANTITY OR LOADING (4 Card Ord)' 1 QUALITY OR CONCENTRATION <br /> <br />PARAMETER <br />(lb-57) (SJ-fil) <br />(;S-0)1 (4A-5-7) O!-bl) <br />NO. <br />E% FRE UENCY <br />'>D <br />L <br />SAMPLE <br />TYPE <br />Or-i7) ANA <br />515 <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS (6'o!I <br />JOl <br />h9 <br /> (n~.6.P/ l <br />- <br />'IL AYD ;G. ~15E SAMPLE ~S Q'1 is^.. ~ QI1~ ',::kRf, n:. .; fr .~}yF ..:r ~.r ..4 ~r ~_ 1 <br />I <br />I MEASUREMENT D 0 iI-r , <br />Vz <br />': <br />AL <br />ttj ~. <br />; E'] 1 ~ '~ ~~~Q>~fi RF^OgS Y f;'=i fi4et#0? '-k${kb>'krR 3aJ tY#^.# . %4'T e,`• ~~~ <br />~ jQS);! <br />, PEPMIT . <br />FFL'IT.'t:' -R7S` YAr(i~ REQUIREMENT jh57 MCI !tl:D i:'k^+:j <br />~: . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~. ~ y~' : ' <br /> REQUIREMEIT ~ - ~ ' <br /> SAMPLF_ <br /> MEASUREMENT <br /> PERMIT ~ ~ <br />~ ~ ~•~ ~~ ' <br /> REQUIREMENT "' <br />f <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ .,A - a~?{ <br />r <br />.h_".' .~ <br /> REQUIREMENT <br />.. ~'. <br /> SAMPLE <br /> MEASUREMENT <br /> z <br /> - ~ - ~~ <br />' REQUIREMENT- - ~ ' <br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER r CERnFr UNDER PENALTY OF LAw THPT I HAVE PERSONPUY ExPMNEO <br />THE WF <br />M4 <br />M <br />T TELEPHONE D A T E <br /> <br /> <br />S.W ~. <br />~ ED HEREIN AND B45ED <br />AND 4M FAMrLIAR WITH <br />OR <br />TION SUB <br />IT <br />ON MV INOUIRV OF THOSE INLYVIOUALS IMMEOIgTELY RESPONSIBLE FOR <br />OBTq WING THE INFOR1.tATON. I BELIEVE THE SUBbVTTED WFORM4TION IS <br /> <br />1 - <br />__ _ TRUE. gCCURpTE ANO_ COMPLETE I 4M PW4RE TH4T THERE ARE <br />P <br />FOR SUBM <br />TTING FALSE INFORMATION <br />IN <br />I <br />G <br />/ <br />` <br />~ I <br />SGNIFICANT <br />EN4LTIE5 <br />. <br />CLUD <br />N <br />NE grJD IMPRISONMENT <br />rHE P05G1B1 <br />TY OF F <br />BEE IB use f imi 4N0 Z~7 <br />~~-9ou1 <br />q$ <br />~y <br />~ <br />µw / <br />pt-YK- <br />~ . <br />I <br />u <br />33 Use 4 1319 (Prwlues under rl¢sr wamms ar ndudr lines up m SI NATUR OF PRINCIPAL %ECUTIVE 7l <br /> i <br />I b <br />b <br />m <br />" <br />e s <br />~ <br />S OFFICER OR AUTHORIZED AGENT A <br />TYPED OR PRINTED nwrrn <br />IN.OIXI aW or maximum ~mpr <br />snnmrm o <br />m~~ <br />: <br />ay <br />)ear:. COD NUMBER YEAR MO DAY <br />y COMMENT AND E%PLANATION OF ANY VIOLATIONS (Rtlrrenre all alla[hmenr5 here) <br />MJti'TOR Y^LATLL'. '1R:aPI": TO'd7N~ A+uNn1LI,r ~rrTpvg7 O1/lA ('n/19; 4F.~'rIT^. D'I" NO LA'='t ""1•: n7/^R ;fITw '";T <br />~"R. D"f°-I.~.ur PP 10-11. GRAR SIIMPL~ ~.VALP~TS F0~ OIL GREASE RE')U?RED _r YTSCc, 7 S`IF"V TF ORSQRY?~ - <br />~- r T~ o 'r ^rMT r r a e n I!T vn r r e n <br />~ EPA Form 3320-1 (REV. 9-BB) PreVlOUS QdIIIOrIS may be use ~ (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.( 0002 5/95052 3-174 3 PAGE of <br />2 <br />