|
PERMfTTEE NAME/ADDRESS p~
<br />NAME r..~"u-; .:. ,
<br />ADDRESS`77"~5 t, 7 ;?
<br />_ QI(lJ F. 115"
<br />:9Gi,EM~'.1~
<br />FACILITY
<br />LOCATION
<br />~clude Facifiry Name/Locanon ifDlBermr)
<br />.. ... _- ~.~ ^1R ~.
<br />~Ti ~T. ''"I, '„
<br />co ,-„s;
<br />r;~`1: '70RRI5 .. ~ 'L=" SPpiT ar¢Y
<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDESf Form Approved.
<br />DISCHARGE MONITORING REPORT (OMR~
<br />^..
<br />`.. OMB NO. 2040-0004
<br /> (3.181 pr-gf T s 0531-98
<br />i
<br /> re
<br />Approval exp
<br /> ~ 1 7 7 71 c rl ~ t)'T ~ ~ - rT n ~ f..t t
<br /> PERMIT NUMBER DISCHARGE NUMBER v _ c ~ u p T o ~ ~~ * r
<br />
<br /> MONITORING PERIOD • -
<br /> YEAR MO DAY YEAR MO DAY
<br />FROM I ':r 1' TO 'r ~ ~ t1 .~`. ..~ •vr •-rH~v^^ I ......
<br />Razf1 (31-33) tzazs) (za-v) tza3e) l3aan NOTE: Read Instmdions be re oo ~peting this forth.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Corti On y) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (49-53) (54-61 (38-45) 49-53) (54-6f) EX OF TYPE
<br />f~Jn AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />(83~v1 ~'a-~f8
<br />(6469)
<br />69-70
<br />.ZL's, ;1TA SAMPLE fi+^r~n r, ~~: ~r:~ r. 'c'c't .'p .° r 'q)
<br />(A ; f' ') MEASUREMENT
<br />
<br /> ~RMIT ~ ~~~
<br />'"
<br />.Pei tlh:sTROSS VrLTI' REQUIREMENT ; t.3fi'k ~~~
<br />30)1~ ~~.~ ~;` r!;/
<br />, s;
<br />`
<br />~
<br />:,
<br />t
<br /> -
<br />, "~ ,:. ,
<br />. ;, T. . ..
<br />~ 4 !~
<br />YL,'.~ IN CUNDOT^ ~F SAMPLE ( n31 ~~~x~~ #hrk#r ..
<br />:i"I' TREAThv.NT PL+~T MEASUREMENT
<br />~~~~D 1 0 U `: PERMIT" 4$Ffl'$T ~~,74'~ti~ ~
<br />i "; ¢4i1Q;~t '?U 4".~ .. 4 ~~ ~3
<br />..°s i,U ENT "'R7S5 Y9L'Ii s
<br />~REOUIREMENT 30pA ~~~+ '#l~ll°4;; !Ax M,^, C ~
<br />~ ~ - . '' -~C'c~ ~- .` ~ 4`i
<br />.. AMU .. I±F.~ ;? SAMPLE #'~"•: ~.. ( '14) y~~...,~ .. ..~.,:... ..
<br />" r ~ U .1 L MEASUREMENT
<br />~Ti~'16 1 0 ~'
<br />~ '.:. pip, I ... C41p OrC0' ,. .. :;T F;=1 .. "~iS'~#5k'.t 1ptQy4 a~.aT# i>It~~lb- #
<br />- {...~ ,: 4 E~:~.LT .~~`i;a~.~.
<br />r
<br />7LUENT GR~~~ ~' •.: REOUI E 7 1~.4~~ *;r-,'1 - .
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMR
<br />U
<br />(~
<br />' ""
<br />'~'w
<br /> REQ
<br />IREMENT ~ -
<br />-
<br />~-
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ,, ;PERMIT
<br />A~f]UIREMENT
<br />~ -
<br />~#;Y .: ~ + •~
<br />,+ „ „" = - -
<br />,,- ~..:. ,~
<br />,.•' .;
<br />9. ~w r -.
<br />~ *°" -
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT .: .. ... ~ .:,- . ~ ;. :,: _ - - -. . -. ' ..;,.- h ~;:.,-,
<br /> REQUIREMENT
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT '~:.
<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I DERTIFV UNDER PENALTY OF l
<br />AM FAMILIAR WITH THE INFORM AW THAT I HAVE PERSONALLY EXAMINED AND
<br />ATION SUBMITTED HEREIN; AND BASED ON MY
<br />/ TELEPHONE DATE
<br />
<br />IZ IC11i.Yd ~'i)~~S
<br />
<br />'.-IViro;~r;e~tel 1:'IF~P,it~Or' INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE,
<br />I AM AWARE THAT THERE ARE SIGNIFICANT
<br />FALSE INFORMATION
<br />INCLUDING THE \ / ~ /T„ ~~
<br />ni ~iG(j'
<br />
<br />~7o-e7n-z7t..
<br />(7
<br />(X/
<br />~^
<br />/
<br />/1~
<br />(
<br />'~,/'l
<br /> ,
<br />POSSIBILITY OF FlNE AND IMPRISONMEM. SEE 19 U.S.C. 41001 AND 33 U.S.C.
<br />4 1319
<br />(Penal(ies antler Have smnxes me
<br />Inclutle Ilrret u
<br />000 entl a
<br />b Sf0 „
<br />SIGNATURE OF PRINCIPAL E%ECUTIVE r
<br />
<br />TYPED OR PRINTED .
<br />y
<br />p
<br />.
<br />mevmum/mprisonmerR Of benseenBmonfhs entl5yaers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION ol• ANT vluu, I IuN~ (Hererence all altacnments nereJ
<br />!L{',~RNAm.. !. T.. '"5 '•.;' Ti it T~^•R °• ^!L">l'I~f' 37LLn.- (1.^ r.7r1 1'1nT,v •1`.•V T~' rv 1 ~_v. -,y_ i. 1•...T :s
<br />:~ ~ ,~.T
<br />C Y.nI P.G. _-. ~'^ ~., - L7, F^. !7 SOFTEN 7~ p87~ra or~n r~:li vM~. ~ ITT. r. .:r a„q~_-r°^c1r-.°.. ~.•f., f•~ n.
<br />r
<br />EPA Form 3320-1 (OB-95) Previous editions may not be usedn n ^(REPLACES EPA FORM 7~0 WHICH MAY NOT BE USED.) D ~ ~ 7 ~ ~ a ? ^ tf T ~ _ T r ~ ( PAGE OF
<br />
|