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PERMTTTEE NAME/ADDRESS (/nclude Facilrry Nmne//ncalion ijD ffereru)
<br />NAME -_ v.^ ~. .. - ^ .
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<br />ADDRESS "I i r / ' ~ : ~ ? :. - "' i : e `. - -- ? r a 4 n ~
<br />FACiuTY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES)
<br />DISCHARGE MONITORING REPORT (OMR~
<br />R45) (Ir- B)
<br />^~f'7~7150 ~^7 ~
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM "' ` - ~ TO ' ' ' 1
<br />Razl/ R1-z~/ Re.z51 RGZI) Raze) (coal/
<br />Form Approved.
<br />„ ~ ~ ,~ ,. OMB No. 2040-0004
<br />Approval expires 05-31-96
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<br />A ~NOTE: Read InsVUCtions bef completing this form.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4653) (54-61) (38-45) (46-53 (54-61) EX OF TYPE
<br />(32an AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />r62G3) 4Na-CIS
<br />(64-68)
<br />69-70
<br />t SAMPLE • •-^axx a`c[: .7? ... .. ( r 7)
<br /> MEASUREMENT
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<br />L i 1~ e SC F SAMPLE ..
<br /> MEASUREMENT
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<br /> MEASUREMENT
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<br />(~ S F = ( MEASUREMENT
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<br />/ REQUIREMENT ... Z()O1( AI(; Rl[LT "X ••, /I. TORT"!
<br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDER PENALTY OF LAW THAT I HAVE PERS
<br />ER ONALLY E7(AMINED AND
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<br />/ TELEPHONE DATE
<br /> AM FAMILIAR WITH THE INFORM
<br />INQUIRY OF THOSE INDNIDUAL ATION SUBMITTED H
<br />S IMMEDIATELY RESPON I
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<br />SIBLE FOR OBTNNING ^
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<br />I~ICF1F Plj ~ ,I)Is THE INFORMATION, I BELIEV
<br />ACCURATE AND COMPLETE. E THE SUBMITTED IN
<br />I AM AWARE THAT TH FORMATION IS TRUE,
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<br />~ PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE ~ I
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<br />. POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. § 1001 AND 33 U.S.C.
<br />' SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED nes up ro Ef0,000 erM a
<br />§ 7315. (PereRies under Ness sletuAes mey Include h
<br />meximum:mpdsonmonl of EefwsenSmonW end5yee/s.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all allachments here)
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<br />EpA Form 3320.7 (0$-95) Previous editions may not be used. (REPLACES EPA FORM Td0 WHICH MAY NO7 BE USED.) ^ ^ T ~ 1 / ~ ~ ~ tt) ,,-1 ~ ~ ,~ PAGE ~ OF
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