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PERMRTEE NAMEIADDRESS /Itl,i F•eWryNSWlxmlm!/Dlpe..q <br />NAME ~ _ -. <br />ADDRESS ,,.,., .. -- . L - u ,... ;? ~ ~ r . . <br />~..r. I , <br />Y ~ 1 ~ L r ~ <br />FACILRV _ _ r <br />LOCATION J .., • -• .. - - i <br />:. 1 .? <br /> <br />NATIONAL POLLUTANT OISCHMOE EUMINATON SY9TEM (NPDESJ <br />DISCHARGE MONRORINO REPORT (OMRI <br />2-161 17-19 <br />'^: 1771.,.5 l <br />PERMIT NUMBER DI9CHMGE NVMBFA <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM i ! ~ .I j TO .^. 'I .: .- :: <br />!262/1 l22-231 121-251 lTf.)71 !]H-1.91 I96.i I1 <br />Form Approved. <br />a ,'.. _ , : oMS,ND.2oaO,goOa <br />.I ~ Applovel ezpireB b~-31-98 <br />NOTE: Reed Inruvetlon brlorr'd6rrtol•Sinp Mir form. <br />PARAMETER !3 Grd 0n1y1 QUANTITY OR LOADING !I Grd onryl QUANTITY OR CONCENTRATION NO FuauENCV SAMPLE <br /> !<5-53 (56611 !3B-s51 !16-53 5651 of <br />!32.371 EX YSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS Ist6L ANAL <br />!64681 !64701 <br /> SAMPLE •.:3 ~:::~.: ;~ -~7~::: ._. <br />~ ..:. ....... ,. <br />~ ' ~` ! ~?) <br /> MEASUREMENT <br />.; i X11 .. 'J PERMIT .k ;Ygfj v:::: Ac;-fs-.,:-: S~.`,= 6.5 y.F+S ~t:;F y°.~ ~~ <br />~>~•+~ ..v <br />1 <br />` <br />T'i5I'L <br />' <br />/ REQUIREMENT ~ <br />~ . <br />_ <br />~ <br />' M ;: ~ tl~~ it : MIEN ' <br />' <br />., i .ter <br />1'OTA1 SAMPLE :T, {: ~:-# ~«"^'> ;I-.`:: ;T :`.k ( <br />~) _ <br /> MEASUREMENT <br /> <br />..S .: i 0 PERMIT .`•:: ffi. Trz:: ~ Ar-x C•;t :ya :~ •: a V ~ , IR='~tY4: ~t 5 <br />~ <br />~'~ .~ <br />' V - <br />/ <br />". ,r A ~! <br />. <br />" .REQUIREMENT ~. ; <br />r <br />' <br />~~ Si r 1 '..V N~ V~ f <br />~..1: J.`,r ~8Tt L1•, ,1. .. SAMPLE ;:G~;.:. yA .; ;;4•, .::.: rF:~'d:.:as ( i:;S <br /> MEASUREMENT <br />... _. :7 1 C. ~PERMIT~ .:a :^~ ~ $":C'.: •^.• -`#.'R {: y,: : :7':~T <br />I^`?AL ~ii•1 ~~ ~l"}/ ": 1:A r. <br />.9 , REQUIREMENT _ <br />+ <br />- <br />...- . <br />, <br />~ <br /> <br />, <br />, <br />r <br />:... ,. r T.:T a i. SAMPLE :_~.-:: •:X -•,.-,......;x .. ..:. ,. ..:. ! <br />1 -1~ <br /> MEASUREMENT <br />. ....~, L (, ~ PERMIT .::w ~~:: ~: <br />~ C';#fa,:^,c ::{: ..'n^+S ysG'.~'< `S.,r`. i. ') !/ <br />' Li'? <br />„ . REQUIREMENT ~ ~ - <br /> <br />- ~ ~ r n ~ SAMPLE <br /> MEASUREMENT - <br />.i 1 .. i - PERMIT #=.<iF: .: .~:#." -. .F #hf,-e; ~ .:$=xL t~tit ~~ 7 !• ! <br />, REQUIREMENT " ' <br />, ~ ~- • <br />r 1, s .'~ ' r r ~ SAMPLE <br />~ D ~~ ;x-Y„:~:' .. <br />~:x ~"~ ~-'~ <br />' <br />.. ,_ EASUREMENT <br />., I ~ ~ PERMIT 3 F:?Il tT $f PLS'.*~ ::=x;cfi,.I .~:',.;~.:t;r;:. ' ~ ~ ~ <br />~~~ v~` ~~ 'k w , . <br />. - ; r i <br /> REQUIREMENT ~ r ~,. _ . <br />.;J'.. ~.~, .'Ai. <br />C ~ - <br />i ~. .. ~ SAMPLE <br />MEASUREMENT .~', ~::,:::: - .. ..:-:: Y.~t;: <br />~ <br />~ /1~. / I <br /> <br />-1 :~~' <br />b <br />~ ~ ~~ <br />7J l ' PERMIT t:>X ;Yai` .t,Li'~: 6:~ :': ;e.^,:0:2 ^'r.~7$Y' 'R^TI1 •~:1'. <br />~ 'i .Lv <br />~F~..1 .:,: ~L.,I.J l.4 :.U :REQUIREMENT <br />• .,I ,.•: .+ •51/7. <br />NAME/MLE PRINgPAL EXECUTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF uW THAT (HAVE PEASONN-LY <br />E%AMINED AND <br />MILIM WITH THE INFOflMA710N SUBMITTED HEREIN <br />AND BASED ON ') /I -, <br />/ TELEPHONE DATE <br />W I III/,11., r/ - ~ <br />r ~~ ~ ~ I t I ~ ~-~-~ <br />J <br />~ 1 ; <br />MY INQUIRY OF TN09E INDINDVAL9 IMMEDIATELY RESPON&BLE fOR <br />OBTNNING THE INFORMATION <br />1 BELIEVE THE SUBMITTED INFORMATON 19 // <br />~ , ~' j <br />~' <br />~' , <br />TRUE. ACCUMTE ANO COM0.ETE. I AM AWARF THAT THERE ME // <br />' <br />~ <br />I <br />^ <br />~ <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCL WINO ~ <br />. <br />/~ <br /> <br />~ P O !~ <br />V ' <br />. <br />' • : <br />O , <br />THE POSSI&LITY OF FlNE AND IMPR190NMENT <br />SEE 18 V <br />S <br />C <br />1 1001 MID 97 _ <br />~~ <br />! <br />~~ _ _ <br />I <br />I <br />/! <br />i . <br />. <br />. <br />. <br />V <br />B <br />C <br />f 131 r <br />lPNWe•• uWr INS memA <br />l <br />n <br />A <br />O <br />r <br />d IO <br />Q/0 &oNATURE OF PIUNgPAL ExECUTNE ' -I r " ~ /' ! ! <br /> <br />TYPED OR PRINTED . <br />. <br />. <br />. <br />i <br />nl•Y <br />a <br />u <br />• <br />g y ro <br />, <br />.n0 ormv:nun Ynpianwnt of MrwwlsmalNa rg6yw•.I <br />OFFlCER OR AUIHORIIED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />OqY <br />V.vmmo•. ~ nnv ten, ~.-,...-,,,..n ..~ ..... ....... ~,...... r,... o. o..,.. e.. .. mV...ne..u here! <br />~:'i LJ.ia...'. 9:ILi .. ''.7, :- a:'f ..Ii .. i. '+ (.' .=1 !PI ', ': - ~ :'. ~ ^r s ~ - ~ .. <br />ii _i ., I;f-_I ..,°L., ')I i, !. 5~J-' JC'~ _ ... 'I"1 r')'~•!:,G~ ?. i^.-. .-T. .'~ Ir, ..'~, ~5. .~_... ~! `. ~ <br />EP~1`Fbrm 3370=T (OB- 1 Pn'doUs aditione Me kb u3BE. • ' ' - ~ 1 EPLACE6 fPd FOR T 0 HI MAY T BE U6ED.1 ~ - • • r - ~ ' PAGE OF <br />