P[RMITT[C NAME/ADDwla! (/nllYd!
<br />F~clilty N<lne/Locafbn if dil/Dent/
<br />hAME~..l r--_- ~_-__..u r.r.
<br />--I_LJJ ~ rt--------- __
<br />-AC1uTT _______
<br />LOCATION ---_-__--_--_---_--
<br />-. • L . .S • h I ! ~ ~ - --
<br />RwnoNwL Fouvrw Nr D1sCN Awe[ [u MINAnoN srsreM /NPDESI
<br />DISCHARGE MONITORING REPORT /DMRI
<br />2 16 17-19
<br />` PERMIT NUMBER oIlcnw wc[ nuM[[w
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO PAY
<br />FROM r • TO
<br />/JO.J/1 IJJJL /JIJ4 /JA1T /JR. J91 /ffi 11
<br />Form Approved.
<br />~-~ - - ~ ") OMBNo.2040-0004.
<br />- - ~ • Approval expires 6-30-91.
<br />,./ . . ...
<br />NOTE: Read instruletion[ hefore eomDletinD this form.
<br />' (! Card Only) QUANTITY OR LOADING (! Card Only) QUALITY OR CONCENTRATION
<br />
<br />PARAMETER
<br />(I6-J!) (J!fi/
<br />(!8
<br />IJ
<br />!63!) (Jlfil
<br />NO. FR EOU ENCv
<br />SAMPLE
<br /> ) -
<br />) (
<br />) Ell OF TYPE
<br />(l2-17) •HwL Y515
<br /> AVERAGE MA%IM UM UNITa MINIMUM AVERAGE MAXIMUM UNITS blfi!) (bl~81 Ib9-]U)
<br /> 6AMPLE ... •• /
<br />\ ) i ~ )
<br /> MEA6UREMENT
<br />
<br />. . ~ ._ ,. .,
<br />°~P£RMI'T' °° s o'y^'i.>to i.0.%+ xsR~~ffit ,~P ~ra' .: :.
<br />~r ~~,}.m aID, x,
<br />° ~' .'l.'.~%i.'ffiis t,Yxa
<br />'.. ,'J~a ° S~.r ~
<br />k a; ~~°~'~a
<br />~ y~~aae
<br />
<br />
<br />1
<br />J
<br />L
<br />a
<br />'1lEQUIRHM ERT
<br />s f
<br /><Qa^6& y
<br />n
<br />s ri«
<br />Ias¢
<br />a
<br />
<br />i.
<br />u: :
<br />Y
<br />¢~
<br />e a~
<br />°
<br />:
<br />°~
<br />a
<br />r_rm s.
<br />~g.s°',: «';
<br />«
<br />...a
<br />;
<br />~`
<br />'
<br />t
<br />~,
<br />
<br />-
<br />
<br />~
<br />s,
<br />°°^
<br />~
<br />
<br />~'~; `n°«
<br />. _
<br />nLJ ° < $ s $
<br />tn .~
<br />~ .
<br />~ g
<br />,x
<br />P
<br />~xRiaF~ .
<br />{~
<br />wr?
<br />k cd .I s
<br />I.,1:1= T -,~ 1.. i,9]Jv V4 ~ ) i~'. n ~ ~ a J)
<br /> SAMPLE
<br /> MEA6UREMENT
<br />L
<br />. JJIIJ .. -. .. ~ ':~
<br />`~mPERMIY''.. >IS~ y~~`„`se
<br />~3 St' .g'~°`r~'e R`~a~~~
<br />~ is .: i. nR"w~ °,~0
<br />,.2;"
<br />'~¢
<br />q 3
<br />*+?~ ~~m PS::e'°'` &~` n
<br />+. /{~~"' S~~
<br />'e
<br />F
<br />r`~ 0A "
<br />'~I~~' °x
<br />~ ~p 6.$q•
<br />J
<br />
<br />C
<br />.REsOUIRE#ENT; .,,
<br />° °: f~ s'a• o-
<br />xs'e Q n
<br />s s •® „ ,
<br />c
<br />o
<br />a a, ~ ~ °r~M..°.
<br />4
<br />~ tti
<br />a a
<br />r®.<
<br />S °
<br />'~~' gg gg x ehID
<br />'°L L
<br />e'c
<br />,y ~.+
<br />J Mx ~•#
<br />~%
<br />~
<br />a
<br />
<br />01
<br />e4<°S
<br />kr 3rsaq`6 F
<br />«dn
<br />`
<br />ns Y i
<br />.a
<br />«~~Y k`.rt xAY~
<br />9\i ~'#F.~ ey~q
<br />-LfL
<br />R4® ,
<br />F'~OL J°. e
<br />m
<br />m
<br />:
<br />_. .
<br />;
<br />1LS
<br />~ , .:a41i =?,i°. r ( - ~
<br />-,)
<br />. .
<br />!
<br />~
<br />. SAMPLE ~ .
<br /> MEASUREMENT
<br />
<br />1 L _
<br />e,'PtRM4Tf:g
<br />~
<br />ed.'4a'R4 ~S"fz sa yy
<br />, °$l Q.~~~~~
<br />..
<br />vw8.;a:e n£a'3.n's`s';a
<br />~ gg
<br />'a.m"iys4'I,ald'sg:
<br />~
<br />:-w :~,`.°a
<br />e~
<br />'
<br />~tx x3 Are ~
<br />~
<br />~'~fis> s<
<br />Ii i
<br />~
<br />QS R£4U1REl1~ENT.
<br />. ,s,c s e`
<br />~~~e`t~ •~~~
<br />' regx ~~x`~ „{ ~ kin I,se
<br />q +°y )
<br />t`'~~{'
<br />~ ~q
<br />•\
<br />~ ~ °~p~
<br />_
<br />.: __
<br />_
<br />s
<br />{ °.rA''; asV
<br />! ~°¢. 'e®o- n3 8
<br />e'!s.'1.(iR'L' . 8$<.AC•:8, ,
<br />~
<br />6"~e .~18 $`rf 8l° «e Y.-.ID~+r
<br />°Y:p FQ .Y ;~L .
<br />618i~
<br />.'>~ ~w ,e Yew
<br />. .1 .IhE6SE .. ... ;~aoAia~l' ~ ) , ... pr )
<br />' SAMPLE t -
<br />~ ~CRSY (,: - MEA6UREMENT
<br />._ _,'~ ~. Q < t'ER#iT: ;g' ly sd $,''Ca9Y~Pi ' .~$8~~'/S 4~°~ , ~~s'
<br />/k~Ae`5''~~a g~Rt &i'7
<br />v~";x Vii.'<m~~`°~aa
<br />o ~ ~ ~a4 w +i s~Sl•~
<br />! ~ <x
<br />~.~
<br />' J
<br />~~'~S YAAA REQU,IREM CHis n. ° ;
<br />`a, °
<br />ya s s
<br />e
<br />$
<br />`
<br />' ' .
<br />° ;~
<br />m~am
<br />;~®%
<br />i« a
<br />`~c '®~
<br />ie~t~ ~ ` a
<br />~~
<br />_
<br />.
<br />, ~ s. ,
<br />+~ a
<br />~
<br />. &c.
<br />: . . ;ri
<br />. .:
<br />°
<br />a ~~
<br />%~.x x ,i i a° li.e,~<.. n, ®°.
<br />,
<br />IM ~C aUUIT' G I) ~- il: a: qY'i U t
<br />!
<br />; SAMPLE ` .. ~ )
<br />. ~. _ _I ~. fE I (7EMT P!„ MEASUREMENT
<br />
<br />_ .: ~ _
<br />V ~
<br />8a P¢RMIT~„ p~+¢~
<br />A A
<br />e°
<br />m,~S«F ~E' q~
<br />e«if ~
<br />...r
<br />«~1-ro;.
<br />~
<br />A
<br />a~$:'vYr a': .°fi
<br />'s «'~~~:^#'r.'e,'CeY
<br />am. &r ~an ~+~3C%~.g
<br />~ ..
<br />°e~F
<br />ia~Ce 4; ~s
<br />.~1e.~m~~s
<br />L
<br />L
<br />I
<br />V7C _ 'R£.DUIREM
<br />,T pp
<br />>>
<br />s
<br />51x14 ~`
<br />~ ii
<br />y~~
<br />~~yy
<br />y
<br />°e~~44
<br />`
<br />~
<br />B~
<br />° a eIDn I~„r a ' B53~a•(
<br />' ~i ~,®°'r'm eA:a'y ~ ffis 6
<br />8`
<br />._.~• ,f
<br />, iF
<br />'-e.° p,e idd'
<br />+. r
<br />T
<br />]f
<br />C L Y $An ~
<br />( ... ~ x
<br />P
<br />Li. A~. ., ,.. :. Al ........ ~ ~y~ :;, ... I -: r,
<br />.. .pIAC„
<br />
<br />r ~ j (/ A „ 6AMPLE
<br />MEA6UREM ENT
<br />_ i J f ~ e/ i t. , , , ^ , , e ° .~ s
<br />FER#1T - c' A`.>.e a~'g ffi;« `
<br />•
<br />rv~
<br />°i' „ ° ° °;, c* e e ; ~
<br />~.
<br />t_
<br />r _ '~ s ' Y' <° 3. Ran
<br />¢!< d is . ~
<br />' ~ s.
<br />v°a'
<br />~s~l ti< n e
<br />~
<br />r (3 °' -
<br />'
<br />~
<br />~
<br />~
<br />
<br />R
<br />I
<br />d
<br />Q
<br />r
<br />~ Iw ae , Ae.,
<br />cg ~Sn ae. °°'
<br />~ sa
<br />,
<br />~ r as ~
<br />a ~~
<br />'a
<br />'
<br />e
<br />
<br />`fA
<br />• ~• ~)'l'
<br />~ /' E,
<br />jT
<br />E
<br />UIR£f
<br />x
<br />R
<br />s 4
<br />° ##ss aass
<br />,
<br />~~~
<br />•:'~'~
<br />. .L
<br />va4rae~4
<br />n<
<br />m
<br />o
<br />.
<br />'Ss s
<br />..
<br />
<br />nax¢
<br />
<br />°
<br />
<br />a-^u
<br />-
<br />. s+ ;
<br />A
<br />.
<br />'x 1 e 1-tm a.
<br />. e e
<br />,
<br />,a ~m .a
<br />
<br /> 6AMPLE
<br /> MEASUREMENT
<br /> °s
<br />t aRPER#tT,a
<br />ns°in.«. s'>+x Al
<br />~~iaiq<<gy°a
<br />'¢a
<br />gg" ^,.a
<br />~°kn°as4 ~.s'°~
<br />xc~, a-xx®n
<br />at
<br />$°
<br />o-
<br />;'.eam
<br />~9
<br /> REQl11k£M6NT1 oo-.
<br />e
<br />ai
<br />r so
<br />~s,s~'
<br />~g w
<br />a
<br />°asb
<br />$<$
<br />g8~' ¢w.
<br />~
<br />`~
<br />a ~
<br />®
<br />~
<br />~
<br />a
<br />~ s
<br />~ .tee s'
<br />ax
<br />,
<br />'~~ aa q
<br />~. ~~ s
<br /> ay.a
<br />q,
<br />ns
<br />< Y ~
<br />as ¢®x a
<br />~° y
<br />~~
<br />$
<br />as 8a a
<br />~
<br />s ~
<br />x
<br />va y#s. .
<br />a.
<br />a
<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTFr uwD[w PENwLiv OF LAw THAT I NAVE PER60NALLr EXAMIN[D
<br />AND AM FIMILIAR w1TH THE INFORMATION 6UBMITTCD HEREIN AND 61
<br />6ED TELEPHONE D A T E
<br />
<br />I
<br />! ;
<br />ON MV INIXIIRY OF iNOSE INPVIDUIILS IMMEdATELY RESPJNSIBLE FOFI
<br />i[it[)rr
<br />.
<br />i,~ii 1'~ OBTAMING THE MFORMATIO.V I BELIEVE THE SUBMITTED INFORMATION /r
<br />~r'
<br />
<br />/ _
<br />• ironmentVi - I,II(-r
<br />5 TRUE ACCURATE AHD COMRETE I AM AWARE THAT iNCRE ARC SIG
<br />NIRUM PENALTIES FOR SU~FITTMG FALSC INFORMATIgr NICWDING
<br />/ ] - • i , i , . ~ q
<br />(n~nl F i" 1?~~
<br />^ I
<br />V
<br />I~~I
<br />' THE POSSIBIUTr OF FINC AND 1MRI50NMENT 5[E IB-USC f 1001 wnD
<br />DUSC f 1319 ,Prmh.r. .Mrr rArv Fmm1o n nrldr /
<br />mvI
<br />nr
<br />n
<br />tl4dn fi1GNATURE OF PRINCIPAL E%ECUTIVE
<br />TYPED OR PRINTED ;
<br />. uy
<br />.
<br />n.d,u mwnm.m rmP.unnmrm„/Mm+rnAm,mlA. and .i .rlrv OFFICER OR AUTHORIZED AGENT A EA NUMBER YEAR MO DAY
<br />... ...-L::ADu-. _ I.- ) .Tn .. ~~~1.. I-I~ .. ,.r rI ).-_ F ..-1~.. _. a.- 1 _L _..• 1 . . ..
<br />• L
<br />T I ~. r; ~J ]
<br />EPA FOfrD.1,TYQ.f TRW. ¢!8)PfBWDYJ OVIDORa maybO UfiBrI. IREFLAC[l EPA FORM T-tO WRICH NAY NOT BE USED.1 / FAG[ OF
<br />
|