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PERMITTEE NAME/ADDRESS (lrbdr fsdlryNadLocana UDlBreen) NATIONAL roLLUTMT DISCNMOE ELMINATON SYSTEM /NPDESI NAME DISCHARGE MONRORINO RFAORT 7DMR) !.•~••. ocr7 tvrrc {nr 1,.CKEi VJ.lC T-161 117-191 ADDRESS yr7 };L[ °[FF h ^~nn nno, ftnO T n i n ~. ~ .~s.-.• . + T ~l y V 7 3 S- U (S t~' I # I Z~7 (J PERMIT NUMBER DISCNMGE NUMBED FACILITY ~ C~ {fuL37 MONITORING PERIOD LOCATION ~. a ~~ r `• L n c ^ 11 R ^ v~-~~~ EAR. MO DAV YEAR MO DAV e:.,f~)N T,~„ C'..,~1c/ CD ?1'J91 FROM qR t)1 :11 TD 9A 03 1 .~'r T g ; J q' I n r ^ 5 ,. F1 N F R A I- N R _ 116111 !TT-T 31 176751 !1617! lT6-T9/ /36311 Forth Approved. n c t r m m F q .r OMg },I~. 2040-0004 ~ A C •. T ,. S, ; T I CApp .o el ipves~05-31 9B (511 P.3 S}:I 12745 F - F7 NA. I. s t'TN(7~ NOTE: Reed Inetruetloru before CQRR letinp this form. PARAMETER !3 Grd Onryl QUANTITY OR LOADING !1 Gid Oplyl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE 146-531 !5451 l38J51 !46-53 !51-51 l3T-371 EX MALYSIS TYPE AVERAGE MAXIMUM ~ UNITS MINIMUM AVERAGE MAXIMUM UNITS lem5sl 15q-561 169-701 LC51) STA?'itE 4!Iuu ACl SAMPLE O~P66rF R{f POCR #fi-^.•### rn;: ,e •+ ( ?)) L !. ~~ I') J A F f' ll (~ MEASUREMENT .T"'.!3 1 0 J ... PERMIT.. H QU EN ~ :~~ a#0'X,sR ~. ~ ~~ O: a`S~KipC ~ ~ RL.^ k0:~`?', ~. :~ >!«,'t#O~#:1R~ ~~~;$~4~#-'sk#.#~.: aF u_ ~ ~~'T~9LP. G6U1F PFt' ^-.NT RE I EM 7. : . ~.. ~:~ - . . :: ~~ ~ ~ ,.~ .. t.(:~U jTAf'~~:g 96HP A^( SAMPLE C: C'kGx OPORC:r .#?*#ql# ¢rg,•r_Se ( 2?~ -t I M .;PHA 1. ~. $ MEASUREMENT ~ %F': •,C 1 U U .PERMIT ~ ~,. ...; .. ~ ~ ~.. . ~ Ai3.iR it4C ~~~; ~ : . ... . i:~:~ #~~IOac«#: .::~ . . ' #.L.~ -. ~ ~:'" ~ ~~~ ~ C.'~#,.rl. : ,FZ_ ~. S,p ., 1'V ,: 755 Y nr REQUIREMENT . . . : : .. .. :: .. •t- ..: e,,. . .... # rc.r+ ..:; SAMPLE MEASUREMENT ~. .PERMIT ~ :., ~.: ~ ~ .~. - ~ REQUIREMENT. ~ ~ ~ t`i'~~~~: SAMPLE MEASUREMENT ~:::...~PERMIT.~..: .:~: .. .. .. ..... ..~ ..,: ~ .. .~ REQUIREMENT ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - - SAMPLE ~- MEASUREMENT . PERMIT ~REQUIRENIENT~ SAMPLE MEASUREMENT ' , PERMIT ~~ ~ .. ......• • q .,.<;:a.: ~^:., ,:. ;:. ,: ~a .. : : ~ : t:: r,.: , :REQUIREMENT .. . : . , : e. `.. .. SAMPLE MEASUREMENT PERMIT ~. :: ~ . .. ., :~ :REQUIREMENT ~.. ::: .: ~ ~ ~ ~ ~ ~'~~ ~ .~. ..~..:~ .~~.~.. ~ ` .. NAME/TITIE PRINCIPAL EXECIlTNE OFFICER I CERTIFY UNDER PENALTY Of AM FAMILIM WITH THE INFO UW TMAT I HAVE PERSONALLY E%AMINFD MD RMATION SUBMITTED HEREIN MD BASED ON TELEPHONE DATE ; MY INQUIRY OF THOSE IMOIVIDUKS IMMEDIATELY RESPONSIBLE FOR T y - •.. G.7/ • N OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS ~ TRUE, ACCURATE MD COMPLETE. I AM AWME THAT THERE ME SIGNIFICANT PENAlTlES FOR SUBMITTING FALSE INFORMATION INCLUDING ` ~ ~.~ ' ' ~ ~ ~ ~ ~ , THE POSSIBILITY OF FINE MD IMPRISONMENT. SEE 18 U.S.C. E 1001 Mp 7J QNATURE OF %IINCMAL E 2 ~ Q U I U.s.C. E 1710. IfIIrWW, rear tlwr mNna m.r Yrcpd~ rr. tp ro t IO,000 7tE TYPED OR PRINTED Anlamn4nun MAn,a•vnrN arbfwwn6maN, An15 YAV..I OFFICER OR AUTHORRED AOENT A EA CODE NUMBER YEAR MO D Y S AND EXPLANATION OF ANY VIOLATIONS (Ra/erence al! sttschments here/ SEF. I. P. 2, PP S-!, P'1o ')YTAIL5 JF TP.ST nR7C`:DUR°. !'£P~RT [.CSD - S'!'AT75mCC'~L POi}%T CCTT1LTp u'tTCq Z~ L?VIAL TJ SD. ')F TE;Sf :)1I:.AXISMS, RND ATTACH ACOTE TOI;ICTTT TE'S1 R~;P03^' ?pnN TO ;1NEe C1DTFj lIF ALL EP o'frn'3 2b=1 'JO 1''P7evioLii edit ~ na'me(r tie use . ' (REPLACES EPA FORM 740 WHICH MAY NOT BE USED.) PAGE OF 00083/961217-1721 I