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PERMITTEE NAME/AODRE55 (Aril FsenYryA'+r'La-erm,. pprQ..,nj <br />NAME _/ . . <br />ADDRESS ..~„ I ~ '~ <br />i • : • a 1 <br />e9.J~:!. <br />FACILITY I ~ ~ ~, . <br />LOCATION <br />T.1 :9 ~v <br /> NATIONAL POLLUTANT DISCHMOE EUMINATON SYSTEM INPDESI Form Approver.. <br /> DISCHARGE MONITORING REPORT (OMRI <br />17-.61 <br />f7 <br />4M~'ND. 2040-0004 <br />- <br />~ <br />•' <br />~ <br /> <br />„ <br />- <br />- -r91 <br />! I N`L`l - . <br />a <br />~, . <br />i~ < i <br />APProve expirse. 05-31-96 <br /> ~ <br />, rl ~ ; , 5 ( <br />, i ^ <br />~ , <br />RECE'~E iED <br />V PERMIT NUMBER DISCHARGE NUMBER _ _ <br />. ' <br /> MONITORING PERIOD - <br />. <br />ry~ <br />SEp 2 YEAR MO DAY YEAR MO DAY __ <br />O Ir7~~ FROM TO ~ <br /> na7n maar vi.7si raaan nn.vm reran NOTE: Rnd I/rlruNolr Mfore ¢omoNtlnO >hIB form. <br />PARAMETER ! fTY OR LOADING !I (ird On/Y1 QUANTRY OR CONCENTRATION NO. FREQUENCY SAMPLE <br />/31J71 /653 (5L5/ (3B-/6f /4657 /5I-el/ OF <br /> EX µ/,yYyy TYPE <br /> AVERAGE MAXIMUM UNI75 MINIMUM AVERAGE MAXIMUM UNITS m1•ee f5r-5e1 f59->'al <br />_ ~~ ,. \ <br />r SAMPLE <br />N~ <br />( : 'r) <br />.. _ <br />. / / <br />( I <br />(L ~' .. ,... MEASUREMENT ~% ~/ n j(~ ~. ~ ~ I N l~ ~ //' I r, \r f1 r, <br />.'.r i:~\ 0 PERMIT ~ I,,..I ,. <br />,:.'.t.•.'I <br />ePTIi1IAL r <br />»~~'.~~=t <br />;''i~~~a'(' <br />[)PTI)'4dk? <br />I ., <br />S.~t^• <br />^•,/ .. <br />.'+7" ~{" <br /> :REQUIREMENT ' ~ ~ <br />~ . <br />. <br />/1 .PII '~ fi'4's.,; «t •.~ <br />f' ', t3S. f- "i ~~' ~xi-kT'?3 ~ <br /> SAMPLE <br />• MEASUREMENT <br /> ~.. PERMIT <br />.. <br />~ ~ <br />~ ~ <br />~ <br /> REQUIREMENT ~~ <br />~ . <br /> SAMPLE <br /> MEASUREMENT <br /> ~~ ~ PERMIT ~ ~~ ~~ <br /> REQUIREMENT ~ ~. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ <br /> REOUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCWAL EXECUTNE OFFICER I CERTIFY UNDER PENUTY OF LAW THAT 1 NAVE PERSONALLY E%AMINED AHD <br />AM FAMILIAfl WITH THE INFORMATION SUBMTED HEREIN <br />AND BA <br />FD O TELEPHONE DATE <br /> <br />\ 1 ~ I <br />1 ~) <br />~ <br />t ; <br />S <br />N <br />MY INQUIRY OF THOSE INDINDUKS IMMEDIATELY RESPONSIBLE FOR <br /> <br />~` <br />: <br />- <br />~ <br />j <br />~ v/ <br />'YI %iI n/'/' T' <br />OBTAIMINO THE INFORMATION <br />I eEUEVE THE 6UBMITTED INFORMAT <br />ON IS ~ <br />I <br />~ <br />~ , <br />I <br />TRUE, ACCUMTE AND COMRETE. I AM AWARE THAT THERE ARE <br />' <br />; <br />~ <br />~ 51(iNIACANT PENALTIES FDR SUBMITTING FALSE INFORMATION <br />INCLUDING !~ ~ <br />/ <br />~ <br />'I ~ <br />~ r ('! <br />; ~~ <br />'. , <br />THE PpS51BIUTY OF RNE AND IMPNSONMENT <br />SEE 19 U <br />S <br />f 1001 <br />C <br />D 7 <br />' ~A. <br />) <br />- r <br />~ - <br />"- <br />- <br />, <br />/ . <br />. <br />. <br />. <br />AN <br />7 <br />IGNATURE OF P111NCRAL EXE <br />I/T <br />E ' // - f~ <br />; r/ i <br />' <br />TYPED OR PRINTED ru'.~5.~~9~^ lMleYr uNrr rhu mllrbr ^rY AN'A•.Yr A+rr w ro ll0.OL0 <br />irprYVnlrrr o/berwr a monehr W SYrra/ C <br />R/ <br />OFFlCER OR AUTHORQED AGENT AREA <br />CODE NUMBEA YEAR MO DAY <br />.n...~,..a nnv gyn. .nnn nvo ..r nn. ..vin ..vno Invrrsncs ai euamnronra recs. <br />EPA Fwm 3320-1 fOB-961 Provfaue editions mey be used. (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.1 PAGE OF <br />