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PERMITTEE NAME/ADDRESS pnclude Facility Name/Locadon ifDiffrnnQ
<br />NAME
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<br />ADDRESS ,..':, f-: :"+i1- cf:; n'I I'-:..
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<br />FACILITY ~~ ~ ~~ i ~ i i ~ F' : f,7 F-.
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES/ Fam Apployed.
<br />DISCHARGE MONRORING REPOi1T (DMR) OMB No. 2040-0004
<br />.., ,. I.,I; ,~
<br />PERMIT NUMBER DISCHMGE NUMBER I ~ ., ,
<br />MONITORING PERIOD ~ ~'
<br />YEAR MO DAY YEAR MO DAY
<br />FROM OC' I ~+ pi. TO iJO 1 l7.: 7] - „,: ~,:~(~~ . L`-;:I i;,~t...;F I~ -
<br />NOTE: Reed InsWdlona before completing this Torm.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FgEOUENC SAMPLE
<br />PARAMETER EX of TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
<br />' SAMPLE "+I ~lf v. !: ;,_ r. ,. !. r. ;
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<br /> MEASUREMENT ~.l l~~ ~ ~ ~j
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<br />ir,,. SAMPLE r.:: v p, +s .a .,r ~:, ;.I q 9r, .,:
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<br />NAME(TITLE PRINCIPAL E%ECUTIVE OFFICER IcervN under penalty of law aim Nla tlacwneM entl ell etlechmerva were
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<br />a
<br />~ TELEPHONE DATE
<br /> prepere
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<br />er my tllrecUon or aupmvtskm
<br />arxnrtlarrs wIN a eyatem tlaelpnetl ~
<br /> b eswre Net quelleatl pereomel IxoDeHY BeNer eM evaluate Ne Inlormelbn '~
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<br />.. ' j: `.. , i~! " C'. { { { submitted. Bsaetl on my Inquiry of Ne parson a pere[ne who marepe NO eyebm,
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<br /> or Nox pareone tllredly reeponalble for palherlnp NB IMOrmatbn
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<br />aubminetl b . to Iha basl W mY knowlatlpe aM belief, We, accurefe, end campleb. - - ' ..
<br />~~SIGNATURE OF PRINCIPAL EXECUTIVE
<br />vl
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<br />TYPED OR PRINTED Iem aware Net Nere are alVNecent panelllea breWminlna false lnlormetlon,
<br />Inciutli Hra aelblll of Ilne aM Im r4somrem br krnwAn vloleYOna OFFCER OR AUTHORQED AGENT NUMBER YEAR MO DAY
<br />cDMMtrv I5 ANU tAYLP.rvH I IVrv V~ HrvT VIULHIIVN5 (HBreTegCe e11 aRBCgmenr5 qe/e/
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<br />roe Fn.m '19/1-7 IREV 3/991 Previous editions may be used. i THIS IS A 4-PART FORM PAGE OF
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