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PERMI7TEE NAME/ADDRESS (IwviJ. Fsdlry Naw/Leranm JDipm.q <br />NAIAE , . _ _ ~ ~ - <br />ADDRESS r .. .. ~ _ , , . - , <br />r. <br />['~ ~~ . - ~~1! <br />FACwrv ~:.; , : ~ , <br />LocAnoAl <br />NATIONAL POLLUTANT DISCHMGE ELIMINATION SYSTEM /NFDESI <br />DISCHARGE MONRORINO REPORT lOMRI <br />!?-761 17-19/ <br />.. PERMIT NUMBER DISCHMGE NUMBEA <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM !' TO <br />!?6/11 I??-?31 !/4151 !?6171 l28-19/ !343/1 <br />:. •; e~ rnrnd. H <br />? A ~ :; 1 V : P c ~' e, _ OMB a°'t~~~r~~1 <br />Approval fz ~gP.05-3 98 <br />~--a. r;,~ ~ I, <br />"L` 1 _~ <br />NOTE: RBBd InBtruetlarr E~fa~ eompbtlnp thiB fam. <br /> <br />PARAMETER I3 Ord only! QUANTITY OR LOADING !~ CAM OnlYl QUANTITY OR CONCENTRATION ND FREOVENCY SAMPLE <br /> 146-531 15461 /38.151 1663 I51-6I1 DF <br />B?J71 <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX <br /> <br />!sa-em <br />ANALVSIs <br />x61.661 TYPE <br /> <br />r69-7a <br />.., n~J ~..Y 7:5 ~ SAMPLE .,-: ( :) ...-. ...': t;: ~: .. <br />~ i ~ ,'t ~ MEASUREMENT <br />,,,; :~., t, _- r! PERMIT :7 ~~.~t~ @~~1~0'?T. F.^~=1 tr ~;~:~;;c:: r:kex;s'~c ::r ~ S:{=.S"?~~;- - ~ N,°. is .`.~ I!1'i it :i <br />'I ~; <br /> <br />~ y EQUIREMENT ~ .IH_^i~" PiAI <br />a NJ^ ~ ~ . <br />• SAMPLE <br />MEASUREMENT ~ /0 <br />~v i C ~ ~ n~ <br />It <br /> PERMIT ~ .. <br />:.. ... .. <br /> ~AEQUIREMENT ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASVREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />• MEASUREMENT <br /> PERMIT <br /> -REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />~ <br />NAMERRLE PRjNCIP/QL EXECUTIVE OFFICER I CERTI FY UNDER PENALT' OF L AW THAT 1 NAVE PERSONALLY E%AMINED AND / / ~ <br />' TELEPHONE DATE <br /> AM FA MILIAR WIM THE INFOI UfAT10N SUBMITTED HEREIN; AND BASED ON /~ <br />. <br />/ <br />~1 i ~ ~{~~ N <br />7 L <br />y MY INQUIRY OF THOSE INDINDVALS IMMEDIATELY RESPONSIBLE FOR ;, <br />. <br />' <br />/,_ <br />~ OBTAINING THE IMFOIIMATOM <br />I BELIEVE THE SUBMITTED INFORMATON IS ~ ~ ~~ <br />~ <br />~ <br /> <br />`7` ~ <br />/' ~ i~ ~ ~~ <br />` r I-~~ ~ ~ I I ~ , <br />TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT MERE ARE <br />BIGNIRCANT PENALTES FOR SIIBMITTINO FALBE INF011MATON, INCLUDING e <br />J ~,~~~ i ~ <br />~~ <br />L7~ ~ ~/^~j <br />! <br />~ _ <br />" <br />1 <br />1 THE POSSIBILITY OF RNE AND IMPRISONMENT. BEE lB U.S.C. 1 1001 AND 70 <br />u <br />c <br />Gt <br />S <br />S <br />e <br />810NA7VRE OF PRINCIPAL EXECI7TNE /." ~% -^° /. <br />-j <br />~ ' <br />~ <br /> . <br />. <br />. <br />t <br />3. e-IV <br />rF Mqr dww mains mry AcEMr Av y ro S 10,000 <br />TYPED OR PRINTED rWa.muNaAn Ana+,.a.,wrrab.I...~smarn..~sswla, OFFICER OR AUTNORRED AGENT ~~ NUMBER YEAR MO DAY <br />COMMCI'1 I S ANU cArLnn~ t Ivry ur nnT vluLAl I Luna IErlserenw ai smcnmmrs navel ; <br />...~d,i1.c ~'i.l. - _~'^~: 3:. .i- .,Y ~- .-:ail,. t, p` _ 'Y" :- '?.II .. I'. _.5[ , ... <br />Epq Fam 3320.1 106-95) PrevlOw edNOm meyrDe used. (REPLACES EPA FORM T<O WHICN MAY NOT BE USED.) PgGE OF <br />