|
PERMRfEE NAME/ADDRESS pwdiiaWryN~Lxulon t/Dbi.wu)
<br />NAME . ,
<br />ADDRESS ti ., , ~ , '.
<br />i •.l• :' `
<br />~'. •Lh
<br />FAaLm
<br />%i.
<br />LOCATION
<br />i l t
<br />MATOMAL POLLUTMf d9CNM0E El1MR1ATgN SYSTEM (NPOES)
<br />DISCNARGE MONITORING REPORT IDMRI
<br />I7-I51 17-19
<br />PERMl71NUM8ER DISCNAR(iE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAV
<br />FROM n . ~ TO 1 ', ~a
<br />I2P211 I12-231 /21-751 /28271 /28-?9l 131631/
<br />Form Approved.
<br />,: a ;- ~ r OM~ No. 2040-0004,
<br />~ I - '[ ' I -;" - ApProvel e%pirse 05-31-98
<br />~ .. I..
<br />NOTE: Reed Inetructlom b~torel enmp'letinp tAie form.
<br />PARAMETER !3 Grd Onryl QUANTRY OR LOADING !I Grd Ontyl QUANTRY OR CONCENTRATION NO AlEOUENCY SAMPLE
<br /> f<5-531 154-51 (3B-IS !1853 54B/ EX DF
<br />l32-371
<br />MAtvss TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS let-63 /54581 (59701
<br />.1 SAMPLE ~ .. I 1
<br />-
<br /> MEASUREMENT
<br />Ii •{~I) i r~ PERMIT ;•~:#~c ~:{:
<br />~ ~ 3: ,L i=:;`- :: ^: ;:
<br />5.~ ... ~.
<br />:: S:;y;k.
<br />~.~.•~.. ~~~~ ~ .~
<br />gv
<br />#L
<br />1~.,, .,..
<br />'
<br />'
<br />' :REQUIREMENT ~
<br />r r ~ e
<br />' 1:'.: r
<br />-, r :°::: t4 .T. Nit r; fi Y.p~
<br />~'f1 ' -~r.
<br />,i'S f : J'° d t. SAMPLE
<br />MEASUREMENT 5.4X":{:# - ... ~~:u? ..:~. is ;:
<br />~ ( : ~!)
<br /> ~
<br />~.;J , .-~ 1 :'; ', ~ ~ PERMIT G?Yk'r.~-k ~ /Afifp~~~.:~ .p ~AY;r~~~ ~ ..
<br />~~ ~~ ~ ~ ~ ~~
<br />~~~ ~
<br />~ ~~ ~ ~ .. .,.
<br />.. EQUIREMEN7 ~ ~ .. . ~
<br />~
<br />~ , ,
<br />Y A
<br />'
<br />•
<br />.. r. .
<br />~ w.~ /
<br />„
<br />I i.: ['.ir :1 °"'TL"AaL:~ SAMPLE -:ckri~:~}~ C;':; ':'.; • ~.. ( T~i1
<br /> MEASUREMENT
<br />1"; '~ .S 1 (: :I PERMIT ;..:...:.:.::
<br />'•. .• gi: ~;-~,~.., .. :.:.
<br />`• r; ,y .., :;; .~,1~
<br />...1 f!1 ''!41, ~ ,.-
<br />.~..! ~
<br />,./~'
<br />./ ~,
<br />;'.n.
<br />_ ,REQUIREMENT . -
<br />:
<br />I:
<br />i.
<br />~ ~
<br />*. /I .
<br />,
<br />: ':
<br />T ;? A i ( ,)
<br />.
<br />:
<br />r
<br />. MEASUREMENT
<br />(^ ~ °)
<br />I. I_ ~ PERMIT ;;:x 'a.
<br />~ ~ye: S- : ~°;-'?'".
<br />i ..
<br />7 , °~ ~
<br />% .. ,' /
<br />.. ~ r
<br /> REQUIREMENT
<br />
<br />~!.. :,?L ~.H=y" SAMPLE ... ..
<br />( ,
<br /> MEASUREMENT
<br />~ 1 G ~ PERMIT .... ...~ .. .. .. ... r,.r .. ~ .. . ,c:«R,'
<br />~..i ~
<br />~
<br />:) :
<br />.
<br />_ .REQUIREMENT ~ ,
<br />Y ~ ` .
<br />C .)
<br />,
<br />~ ~
<br />.
<br />r iic Cp V':'T
<br />,. SAMPLE . ,l t:; :~.. _.:.., ,;
<br />~ ... ~,. ,.
<br />~~ ~
<br />,
<br />.
<br />.
<br />.
<br />, EASUREMENT _
<br />I .,
<br />,
<br />~
<br />_
<br />_
<br />~ M :
<br />•
<br />..) 7) ~ C; ~ PERMIT '- :.. ', -i'? i? =. 6"? 1' :' :..,}': fi ': :: ,:.. rc r (x ~_;; +~; ; .r;.::::.:- r o ! .
<br />;. r ' v f r: II ' i'. J -.. 'I :REQUIREMENT ~; :) `.' ' Y i, ! ..
<br />'J I
<br />I US
<br />;J': 'c i. SAMPLE .. .. -, ( 1 -/)
<br />_
<br />f
<br />.
<br />' MEASUREMENT
<br />i U 1, J ; L
<br />i. 1:.
<br />7J, 'IS 1 0 PERMIT ~~«';t: :;*kXar~. _.. ±~,.,,.. i;'P')R: 'Ti)XA[. .' °+.
<br />r"':,J;_,:C dlt0"- 7r. .REQUIREMENT 1'1.'9:' ACf ~~i?T? "~I. ..~,
<br />NAME/TRLE PRINCIPAL EXECUTNE OFFICER 1 CERTIFY UNDER PENALTY OF
<br />AM FAMILIM WITN THE INFO LAW THAT 1 NAVE PERSONALLY E%AMINED AND
<br />RMATON SUBMITTED MERDN; MD BASED ON ,-^, n , TELEPHONE DATE
<br />
<br />I, 11 ~
<br />r~ I C A (' I.
<br />11 ~ 1 ~I-
<br />MY INQUIRY OF TNOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />T
<br />INFORMATON
<br />EVE T
<br />UBMITTED INFORM
<br />TON IS
<br />I BE
<br />E /
<br />
<br />/
<br />~~
<br />'~
<br />~ ,
<br />OSTNNING
<br />HE
<br />LI
<br />H
<br />S
<br />A .
<br />,
<br />"
<br />-
<br />
<br />'~ TRUE, ACCURATE MD COMPLETE. I AM AWME TNAT THERE ME
<br />SIGNINCAM PENALi1E9 FOR SUBMITTM'O FALSE INFORMATION
<br />INCLUDING ~ ~
<br />. ;!
<br />~ ~
<br />i
<br />YG' ~ ~ E7 E_ LIT .. ,
<br />THE POSSIBILITY OF RNE MD IMPNSONMENT. SEE 18 U.S.C. E 1001 MD 33 SIGNATURE OF PRINCIPAL EXECIlOVE r /~J ~? I
<br />r c~ ~ 1 /^
<br /> U.9.C. E 131 e. lPeWel.. /K.r ewer Nrvna ro.F Arcw.N /MS y ro f /0,000
<br />TYPED OR PRINTED .nsnnrrimnr irw+learvrunr olArrw.NrenlmOb.ndb rrral OFFICER OR AUTIIORRED AGENT CpDE NUMBER YEAR MO DAV
<br />COBAMENTS AND EAPLANATION OF ANT VIVL.w INNS Inenrsnce m/ artecnmenrs nets)
<br />.-..:1.°r.,L` ,. .. ['.: '..; li'F :,I ~:. .. 'i.! I: \.-i,,..Fi~ t ..:I' '.~~. .•T_"'.. 1' ..}* ~i : ~ _
<br />.
<br />.. _~ v 1" )'I 1,- ~["'S JI:. I. !I-. - - Anvi..., i_ 1 .~1•>~. "' .4 '. i,. ~ .- ~ - I.-. , -. '1~ .); - .,-'
<br />EPA For'fri 9320-T ( 8- 51 PrevioJe a itiona m ~ e uAea: ' ' ' ' - • (REPLACES fPA FORM T~ HICH~ Y NOT BE USED.) -' L ' ' • ~ r I ; _ ' ' , PAGE OF
<br />i~ 7i~ ,
<br />
|