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D d 13 v [ <br />A".'IYe ,r•IYA .Sh~•.~o~~.avoo Ar N2D_ <br />NATIONAL POLLUTANT DIBCHMOE ELIMINADON SYBTEM NPDESI FOnD APProVed. <br />DISCHARGE MONITORING REPORT lD~R/ O~ No. 04O 0004 <br />r¢ 766 nl-rsl oort)SE A'PA POND nu7b ff~+ rr. <br />r ~ n n n t. n w („ Q w R ._ a~ A'pp}ovel ~sl~nes (SS-31.8 <br />1~ IZ7U PERMIT NUMBER DIBLHMOENUMBER 12345 <br />F - ''TYRE ~ <br />~/ 1sU23~ MONITORING PERIOD ° f RnP <br />YEAR MO DAY YEAR MO DAY __ <br />FROM vy Ol 01 TD 98 ~3 3 =~c ~![ I';CHIRGP ~ ~ aa: <br />- 176711 l17-731 /7a-751 rPE-s7~ r]9-991 r3asFl NOTE: Reed IwetrucUone be~ore ObTmPleTln9 this iOrm. <br />PARAMETER !3 G.d On1Y1 QUANTITY OR LOADING !I Grd Ontyl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE <br /> 146-531 15461 /38-051 !1653 !546/ <br />/37-371 EX ANN.rSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS m7.e~1 !6468/ !63701 <br />pH SAMPLE ;t gtaCCS- t7at QAr ~ ^r..^:tC-,. -, <br />~ <br />( I <br /> MEASUREMENT . <br /> <br />U l/4 i)il L ,7 U PERMIT ~ <br />...... :, '."~ <br />~ aaQ.G+i'R <br />~~ <br />~ aQl~#Ncg4 <br />~ <br />tC*.` <br /> <br />5 ~ 5:.. .. <br />': <br /> <br />~ <br />?CIRO~.aI$F' <br />~ <br />:~~'e U~ ~ <br />~ ~ ~:~ <br /> <br />~ ~ <br /> <br />I(F~rt <br />~:~L:Y <br />IN'~x ^~I <br />1 <br />. <br />,_.. 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H T ^ I, R p MEASUREMENT <br />tiUr11U 1 U U ~ PERMIT.' <br />E ~R3P~~R~f.~~~.~. .~F1Pc7~A1' ~' <br />' ~ ~~.~'ra°~oai~ ~ ~ ~fVY'IR'}~°A' ~ ~ +°731.t.V#~~~ #'?a ": ~W <br />~~GLK IN3IA^ <br />- <br />~~FPI.U~N-• (;RJ S Pa.LI; ~REQUIR <br />MENT~. ~ ~ ~ ~ <br />A >t'Y'C ~ <br />~ ~: <br />'Str010 , <br />%IL f1ti~I :; :i F. IIS[' SAMPLE ;xa C:txC ( 94) eOII:kG: ,vCQ:Xfi CfifiS+t=Q <br />Y I ,!1 A L MEASUREMENT <br /> ~ <br />14U66 1 U !) :~,. ~PERNIIT.. <br />' #'.AOr:t¢C':a <br />::. : HCP©R~T ~ ES=1 Q..w#~.#'/x~n. C~S:/<ttEtr g#tQiQl~.+pr~~: c;*!,`a <br />... <br />' <br />' <br />~ ggvLTVlgI!qr <br />c r REQUIREMENT <br />2:F'PLU..&'.* ...RUSt VA I[ :. ....._.,~:... ~ <br />~. <br />. '~.. .... .._,~....~. <br />:.. <br />;..: O.. <br />.~.,. .'.: 'R, .. NQ: '..::.:. 4Y`t ~~_ <br />~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDER PENALTY OF lAW THAT I HAVE PERSONALLY EKAMINED AND <br />TELEPHONE <br />T <br />D <br />AM FA MILIAR WITH THE INFORMATON SUBMITTED HEREIN: AND BABED OM A <br />E <br /> MY INQUIRY OF THOSE INDINOUALS IMMEDIATELY RESPONSIBLE FOR <br />n <br />1C.r <br />S• I Co J OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />~ <br />~ TRUE, ACCUMTE AND COM0.ETE. I AM AWME THAT THERE ARE ~ ~ <br />~ <br /> SIGNIFICANT PENALTIES fOR SUBMITTING FALSE INFORMATION, INCLUDING ` <br /> <br />.4 e•r ~ \ / <br />THE POSSIBILITY OF HNE AND IMPNSONMENT. SEE 18 U.B.C. ! 1001 AND 31 <br />U <br />B <br />C <br />! 1310 <br />/RPWOirF Ines elFa Ib1VM1F IOF <br />i/KAAF (nIa I <br />ro S 10 <br />000 _ <br />-I ~ - I <br />IONATURE OF PgINCIPAL EXECUTNE <br />Z. T <br />. O a 1 <br />Q <br />I <br /> <br />TYPED OR PRIN . <br />. <br />. <br />. <br />p <br />, <br />Y <br />.Mamvmun im <br />ismwrrr OEblwwnemoAer <br />rW 6 <br />I <br />!OFF <br />E _ <br />N <br /> p <br />, <br />YFSn. IC <br />R OR AUTHORIZED AGENT CODE UMLIER YEAR MO DA <br />J9 uAY AVF.fiFCS I4 HISir:ST '47hT~1LC 4V :. DUR[Y; p?R[0~ RFPU°°?D. OIL ~ :Q°A :c - SF: P. I.a.l.~~ n, 9. +qg <br />TUT1L IRD!1 LL~[TS Y[LL Pi° ;1111Y:?D, 11VD SF.TTLEA4L~ SIILIDS LI9ITS APaLTa6 PqR C=1~°i!~].4YD ).'rrrT^ EYFV^'-~,'T^ <br />EPA Form'3370'1'168'95 'PPe3iouli editlona eb tie sed:' "' "• `I P S EPA'F RM 4 HIC 'MA NOT BE USED.U - F "` " ~' "' ~ -• ~ AGp OF <br />00051/961217-1~"'; 1 <br />