--
<br />I+ERMIFYfEE NAME/ADDRESS QeelNrieNbry Ne~/Tarnlen dDbinnr)
<br />NAME
<br />rt . , ; :.
<br />~ ADDRESS ,~, I ~,; _ -. ~~ -_ ~ ~. -
<br />PfU. ,
<br />FACILITY
<br />)~' '
<br />LocAnoN
<br />NATIONK POLLUTMT DISCNMOE ELIMINATION SYSTEM (NPDESI Form Approved.
<br />DISCHARGE MONRORINO REPORT IDMR) OMf~ No..2040-0004
<br />1.761 77-19) ~ ): L _
<br />lrl , / _, , ;~ r- ., - -~~ - Appr6vel ezpiree 05-31-Sg
<br />PERMIT NUMBER DISCNMGE NUMBER '_ I. /
<br />' - MONITORING PERIOD c ' ~'
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ') t . 7 l TO ~ T -. .:: ;: - -, . z - .. (__ I .:.. .
<br />I1P1tl /I?-131 /14151 /16-171 ne-asl /3asn ~-NOTE: Rnd InetrucNoru before eoTnPleTlnp thb form.
<br />PARAMETER !3 QN OnlY1 QUANTITY OR LOADING !e 6rd Ontyl QUANTRY OR CONCENTRATION NO FREDUENCr SAMPLE
<br />
<br />Is2
<br />371 (x6-53 1546/ 38-15! 146-53 (GI-6t/ of
<br />- EX v,NUYys TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS /sleai ,
<br />(µ5g1 169-701
<br /> SAMPLE
<br />~ ~ ~ ~ ' ~
<br />~ ~ ~ - -
<br />'1 ~~ A ~~ ~~ ~~
<br />~ ~11
<br /> MEASUREMENT
<br />._ )
<br />,. 1 _ .PERMIT ~
<br />:7 ~:.:M~=:F
<br />#S-:-k:~>:1 r.= i
<br />~,`.
<br />Fir, ~~
<br />ext: r:~:k
<br />X
<br />').:` ~.
<br />I: ~.t~: t.y
<br />''.~;-,
<br />-
<br />- ~ ...~ .. REQUIREMENT: ~ ~ ~ ~ ~
<br />:: n t t : v 1 ~~' . ~?!tt /t M .. ~
<br />:.p.. q '
<br />s ~; / [ ,1'" ~l L SAMPLE .. , ... .. Y . ... ... t ~)
<br />(
<br /> MEASUREMENT
<br />
<br />,~I ,; ,. " .) .:~~. PERMIT. ~~
<br />~ r%~:`4Y~~
<br />~ ~'?~X~n II#'.''~~ .t ~`:: ~ ¢;tw .p:~r 3K ~~ ~ ~ ~7fl: ~ <. I-E »''~(~ 'MA{i
<br /> fiEQUIREMENT
<br />
<br />-
<br />~ w. .,
<br />.~~p L'-~'; LF;
<br />~.; I, ::'SF ~ SAMPLE .. .. .. ...: .. ( ;' ;)
<br /> MEASUREMENT
<br />~v _~~ i it „ PERMIT -.., :`°Fi'=: ~. ~ ,-, ..~~.;:~: ..~ ~ ~J ~'!'1~l: ~FAb ~~:
<br />`r - 9~~:^f 4
<br />Y'i '
<br /> REQUIREMENT . .
<br />, ~
<br />A L
<br />/'. " J r SAMPLE .. ... ~ ~
<br /> MEASUREMENT
<br />~i... ~ 0 ~ 'PERMIT .. .... ~ .. -... ..- 3.'> 7
<br />.:. ` '/ .. r..
<br />v'~U~' ;. 'r .I,;.; v. REQUIREMENT Tt'1 [, a4 ,`i1~.i'l ~"Y. _/~ .;3""'
<br />~_. i ~ ~ !~ ..tiff SAMPLE .. .. .. .. - . - .. 1 )
<br />( 1
<br /> MEASUREMENT
<br />~ , -r h .. PERMIT -. .--".t; .... ... sa>r 4~" ~ ..~?:x:Y E~fl ~ :]p!,
<br />a ~~a :. ,
<br />I. U i'.'17 v 3 "-~ 5 •; 'i .
<br />~ REQUIREMENT ~ .
<br />f.
<br />L.. 1 ,,-r);.-.: 1;': SAMPLE ( `~ .. - .., ..
<br />;r . ,I ." ~. • ,~ r MEASUREMENT
<br />.~ . ~ 1 PERMIT .. „ ' i .i ~: D;'; g: ^- .. .. .. ~:.@,~ ~ . ... { :' r ~ r
<br />:, .
<br />.e r'LUF'- 1' ~:, '-i'"~ `i c;,l. REQUIREMENT ~~)J.i nti'.; '%~,I[•Y ".: +.
<br />~Ji,1L'Sf YCTkL SAMPLE .: ~ .. .. .. .., ( 11
<br />::; 5'J L V t. ~ MEASUREMENT
<br />r~_')~ >, c~ ., PERMIT ..`:;e •",r.: '.` ... r. ... ".' ~~F %~., i. .,~a}:- :~:°}. l.r:Al. ,., y
<br />;, L.~ r[. rl ji V ~; -~ -REQUIREMENT ~ .. ,"tT?~ .A'L; ')i'. i.f `11:{ N /:.
<br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I CERTI
<br />AM FA FY UNDEII PENKTY OF LAW TNAT I NAVE PERSONIIIY El(AMINED MD
<br />MILIM MRTH THE INFOi1MAT10N SUBMITTED HEREIN
<br />MD BASED ON TELEPHONE DATE
<br />1 '~ . I~~ n
<br />k~C 1
<br />~ ICIX'I~
<br />~ ;
<br />MY INQUIRY OF TNOSE INDIVIOUKS IMMEDIATELY RESPONSIBLE FOP -
<br />/
<br />/
<br />-
<br />1 OBTAINING THE INFORMATION, I BELIEVE THE SUSMITTED INFORMATION IS
<br />TRUE
<br />ACCUMTE MD COMPLETE
<br />I AM AWME TNAT THERE ME 1 /
<br />
<br />L ,
<br />.
<br />SIGNIFICMT PENKTIES fOR SUBMITTNO FNSE INFO7V.IATION
<br />MCLUDINO V ~ y
<br />
<br />h' 1 O(° ~ }
<br />1 ,
<br />THE POSSIBILITY OF RNE MD IMPNSONMENT
<br />SEE 13 U
<br />S
<br />C
<br />1 1001 MD 9J
<br />1 7O _
<br />a ~
<br />/
<br />~
<br />~
<br />, .
<br />.
<br />.
<br />.
<br />1 t 31 e
<br />/A
<br />1
<br />f
<br />U
<br />S
<br />C
<br />I
<br />M SIGNATURE OF PRINCIPAL EXECIlTNE ~
<br />/
<br />'
<br />~ y /
<br /> VIN
<br />e. InWr e
<br />.
<br />.
<br />.
<br />.
<br />e~ mem. rrNr
<br />c/ude
<br />vwa He ro s 10,000 AREA
<br />TYPED OR PRINTED .rrwmuMUrr irm+laanr.+t e/bA.eersmenM.W 6Yera/ OFFICER OR AUfNORRED AOENi CODE NUMBER YEAR MO DAV
<br />OVNIMCINI, ANV tAl'LANAIIVN yr ANT V WLN I was Irtele/BnOe en erteCnmlOfJ ne/e/
<br />~ i i-'. fi , ... "1 .. 1 ,' ~ ~ .. r ... ! -~ i. / _ _ . ! .: f r l l , _ 'r • ,u i I _ . ~' L . ) / - r
<br />_ _ / ~ '.
<br />T
<br />EPA Faarti 3320.1 OB- 1 Previous editions mey be used. -' ' ~ (REPLACES EPA FORM T40 WHICH MA NOT BE UGED.I ~- ~ PAGE OF
<br />
|