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PERMiTTEE NAME/ADDRESS (Ixrude Faciriry Nmne/Locanon iJDifferent)
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<br />LOCATION
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<br /> (3 Cerd Ony) QUANTITY OR LOADING (4 Cerd Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4B-53) (54-67 (38-45) (48-53) (54-67 EX OF TYPE
<br />(32J7) AVERAGE MAXIMUM UNRS MINIMUM AVERAGE MAXIMUM UNITS
<br />ANALYSIS
<br /> (6x83) (54-68 69-70
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<br />1 ~ REQUIREMENT ... l(tp f( Atli - DAILT MX ~"1', hOA A ~e, ,.
<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTI
<br />AM FAM FY UNDER PENALTY OF L
<br />ILIAR WITH THE INFORM AW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%AMINED AND
<br />IN
<br />AND BASED ON MV TELEPHONE DATE
<br />
<br />Richard :'ills
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<br />~~lental j'ana INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING S IMMEDIATELY RESPON
<br />E THE SUBMITTED INF
<br />I AM AWARE THAT THE
<br />FALSE INFORMATIO ;
<br />SIBLE FOP OBTAINING
<br />ORMATION IS TRUE,
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<br />POSSIBILITY OF FINE AND
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<br />EPA Form 332O-1 (08.95) Previous editions may not be used. (REPLACES EPA FORM Y-db WHICH MAY NOT BE USED.) ~ ,t T ~ 1 / ~ a D!(T ~_ 1 ~ i tl PAGE T OF
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (OMR~ OMB NO. 2040-0004
<br />R-t51 fn- BI v . ~ ~ ~,
<br />' 1 '1 Z ? 71 S 1 n ~ S / e, ~ ~ • n •, .,) APProval expires 0531-98
<br />PERMIT NUMBER DISCHARGE NUMBER p _ n r .• , . -, -~ .. ~ ..
<br />MONITORING PERIOD ' r .I ` t r ~ ~~ '^ n cn r ~) • r ~ ~ v
<br />YEAR MO DAY YEAR MO DAY _
<br />FROM - ~ 7 ) TO ~ .I J ... .~ ~ n r <-i-f+ ~ -, f .
<br />Izo-zt) tzz-zs) (za~z51 R5~zv1 lze~zB~ (so3n NOTE: Read IOSVUCIlOnS be a cortjQleting this forth.
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