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PERMITTEE NAME/ADDRESS pnclude Faciliry NamrJLxmion fDifferenQ <br />NAME iYi,.;.J_ _. ..rr r ...,ir `-.i^p. <br />ADDRESSn r :I ~: ; ! , ~ - ~ . r ~ ! > ;- .., A . ~ ,. <br />~, <br />= ~~~: ~D r TrT ...r .. . R~r ._ <br />r' °gi~L.....1nr ^'1 9U15i <br />FACILITY <br />LOCATION <br />T ~. lli M~~.{?r~ _'~. '' .p}i. i'AL A*NT <br />NATIONAL POLLUTANT DISCHAAGE ELIMINATION SYSTEM (NPDEB) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR~ OMB ND. 2040-0004 <br />0461 ! p- B! • A ~ ~ ^ <br />'.7 D 7 7 71 41! •111 T § I r' Approval Bxpir0905-31-98 <br />17c v-!! <br />PERMIT NUMBER DISCHARGE NUMBER c _ o r .+ e r :~ i.t r <br />MONITORING PERIOD " T y P T ~ T n ~~ ~ q -r`n cn r ~ ~ • t ~ ~ •. <br />YEAR MO DAY YEAR MO DAY _ <br />FROM .T P 7 TO '1n ~1t r,.. ~.^ ^. orneci^~ -! .....:- <br />i-- <br />rzaxrl Iu~za1 Ra-zs1 tze-z~/ (28-29) (sa31/ NOTE: Reatl Instructions before completing this form. <br /> (3 CeN Ony) QUANTITY OR LOADING (4 Cent Onry) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (46-53) 54-8T) 3B-45J (4653) 54-61) EX OF TYPE <br />(~-3n AVERAGE MAXIMUM UNfiS MINIMUM AVERAGE MAXIMUM UNITS aNaLYSls <br /> (62-s31 (64-68 69-70 <br />i:t;)~, J 4 SAMPLE ,.. .G C'< r-`4~": `• +k .~fFh;: '- „ <br />( , <br /> <br />(A °"I <br />MEASUREMENT ~ 1 ~ / (/ I ~~ U //' v <br />i/CllVti 1 '] .f .~-,PERMIT 1191 4 .. #~~ # ~ 3y.S '- •- •4 ~- <br />Q ~'.~ <br />~~ - <br />S,fFLUt:Nf ~F755 JACIIf <br /> <br />_ REOUI EME_NT <br />R <br />_ -' <br /> <br />,., , <br />I., <br />- <br />~-~~ ~ <br />:~ <br />V ' <br />~ <br />''.3ElbA 11lG <br />D1iLL ~ <br />• <br />^,rr - , <br />~ ~" <br />~, <br /> <br />~L")e, <br />1r rD•lonr^ n•r <br /> <br />SAMPLE <br /> <br />( 03) <br />oc~~x~~ A y <br />IiYYA},~-'SS <br />rr;. <br />-X: +`~ <br /> <br />~ <br /> <br />P R 81' ? H~ A i' "" N T ^ L A N <br />MEASUREMENT <br />t ~ ~ © 3~ 01711 <br />SOGSU 1 ~' (i PERMIT -~, ~~ !D`R} a~~ Zi~`.: ` #fi#~ - "-41 t`- '~"M .-. RA# <br />PP"'LUE'NY %~5'; Y4S.Ut REQUIREMENT. b~, Sru DA#~1.T±.~,= nGR <br /> <br />~ <br /> <br />~i.< •;,• <br /> <br /> <br />-.. <br /> <br />~ <br /> <br />p< <br />'~ <br />a <br />:L:. ,., J f; ~'" ,';c <br />L T?;+AL SAMPLE <br />MEASUREMENT 'Xr~h:? ( '!4) .y..,t.t,~ <br />.. 'k ~.t,:fit kyyx~.,, O ~ 31 IJi~~~ <br />" //7u5 1 7 7 -PERMIT ~-tO9t ~ • R i=1 ~ .. ~e;<#qr 'k##EI#+A #1X'-01#'1X7~:.Q v# F ~ ~ <br />R'v~Y' <br />:~'rLUEN7 ,N:1..4 OAC.7E ~"IREMENT ~ INSi ?~JtL 40=9 ~P•. ~ b <br />' <br /> SAMPLE <br /> MEASUREMENT <br />~ <br />.~ PERMITy`~-. ~. .., .. - :e <br />::,c <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :. - ;. , ,. x <br /> .REQUIREMENT .: s ": ,; :' ' ~. - ~. ;~ ~ <br />, - <br /> r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. - - - - - - .- - :+~ <br /> REQUIREMENT -" - ' <br /> 4 <br /> <br />SAMPLE _ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL IXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF L <br />AM FAMILIAR WITH THE INFORM AW THAT I HAVE PERSONALLY E%AMINED AND <br />ATION SUBMITTED <br />ERE TELEPHONE DATE <br /> H <br />IN; AND BASED ON MY <br />°.icha rd Mi I Is <br />' INQUIRY OF THOSE INDIVIDUAL <br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />E THE SUBMITTED INFORMATION IS TRUE, <br />^ <br />w ^ <br />.Mar.so?r <br />Environments ACCURATE AND COMPLETE. <br />PENALTIES FOR SUBMITTING I AM AWARE THAT THERE ARE SIGNIFICANT <br />FALSE INFORMATION <br />INCLUDING THE <br />~ CU~D_C70_Z'~~= <br />~ t <br />/ ~~ Y`/' <br />!J <br /> POSSIBILITY OF FINE AND IMPRI , <br />SONMENT. SEE to U.B.C. § 1001 AND 33 U.S.C. _ <br />SIGNATURE OF PRINCIPAL IXECUTIVE o I <br /> e end suds I/ma up ro Slo,ooo end ar <br />e ~ <br />~ <br />~m m~n~ <br />s <br />~ <br />~ <br />e~ <br />m <br />TYPED OR PRINTED i <br />w <br />im <br />p <br />n <br />ir <br />e <br />1 <br />v years./ OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />..ro N.vww.n nvn yr ti.. .+w... .w I^ .o. o.me a.amwmomo nmor <br />.."L"r:RB ATE: Lr•'TrC °rJ° :, 5474 Cyr°L'4 ~f.° .i lT.rO" (r. •T^ el'r) r:. nr,Y 1••7T ra - 7^_?. =.t_i7 e, n-.^,^-T'~ .". <br />.: L.:T'!~ii• TRY 7. .~, . Lre °,1Rc'-IO~D?V lc Pa 77~ Ri'-t l!T7.^v oF. ...vim 'T TT c ..f _.-er.• f' , r n.• n <br />•n•ruly ~a z:nt rr^ •r~ ryi-n,. ~ ^P ~^ nrT`:^ r F/~ <br />'~ <br />EPA Form 332O-1 (08-05) Previous editions may not be used. r `(REPLACES EPA FORM T-CO WHICH MAY NOT BE USED.) ~ n! ,! c r 7 - ~ II T ~ _ T S ~ I PAGE OF <br />