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PERMITTEE NAME/ADDRESS (Include Facility NamelLacarian if Di$crenQ
<br />NAME i~-. l]'. ")I7\;.R1 c - "t, I.~'.
<br />ADDRESS ~ ~.. _~ ~ - ~~ .1 - ~ .I ~.:
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<br />FACILITY ~ + ~~ j ~ + ~ ~ ~ L .. ~. ;
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR)
<br />:':1+1 1r~ ~~~~ 1..
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~' 1 > ? ~ 1 TO ` i ' ~ .f 1
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: ,Read Instructions before completing this Corm.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br /> EX of TYPE
<br />PARAMETER
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS aNAf'YSIs
<br />" ~ SAMPLE ...._.. ., ,.. ... ... ( ~ ~~
<br /> MEASUREMENT
<br />_ ': J J 1 i PERMIT #CIF #p KO#>a#1r ~ {y.5 #4ff#'to# -: R~0 ~ E~Y $SI?-
<br />~. i' 1' =.! l.ib Y+, L,,. REQUIREMENT -~- - Ptl ~Iik~Ux MAX (~~)~ SU
<br />lLI '~:, I'.,. .L SAMPLE ~~ -, -'_+'~. «;=t=a ~i' ( Ly)
<br />., .~; ~ ,;.t MEASUREMENT
<br />i' ~ ,) ' 1 ,: U PERMIT '7=#:+i)<#1#" .. ~ 41# ~ .~ :70=Y~t #!~':', . - '~'~ 7.D '±! ~ ~ BA~B~
<br />'r. )~. '~i ~ ~)_~~ J:,I; REQUIREMENT -~ ~301)A AYu DASLY fl /' K^u L
<br />;, r ; - . , r T L r. '.., i, ~. SAMPLE .~:: ,, - ,... r:.t;: ,: r: ( Z 5
<br /> MEASUREMENT
<br />;.. ,. 1 ~ U PERMIT #O+ntsSr# #3#aQ#- C#Ot~4# R~POItS~ FEP
<br />I 8A-8
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<br />REQUIREMENT r:' '-' 3DD AV6 DAZ ~
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<br /> MEASUREMENT
<br />U .':,-. •- i .1 0 'PERMIT ~O'ti ts•kt 4#Itr#as 44++va# ###4#:~ :t ~~, -. kj`. ~ ~~~
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<br />1 REQUIREMENT ~ - ~ - - -
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<br />: I, SAMPLE " r,::: ~: ~: ... .. ( ;. ~ )
<br />~,i '. ~:_) MEASUREMENT
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<br />! PERMIT -S+#s`#SS= hqe ak#{>: 4.'"j##tiY Cs 3. rJ 'J. 0 fx7 '. NC?/' S-
<br />• - I' ~ 7.4 L J : REQUIREMENT '_-:'- : 3 A Y U . U :~ yC' .
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<br />SAMPLE
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<br />„. _ ,, , „ , 1 MEASUREMENT
<br />' i7 ; i ., C PERMIT RG~0$1' _ `" ~PQ$ ;~-~ : %~,.. ~'_'~ ~[#4,'#1Y=IM': `~ `#6L$#IRR'a>t' #tr- '~`s``:. ~~P.RiLY
<br />~i.li _•ri ..: PALU: REQUIREMENT jU t76 Api> ~ D,AiLY Zx .' .
<br />' :.: . i SAMPLE _ ~ . ~ ,
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<br />,. ,- _ MEASUREMENT
<br />/„_ ~ ~ i ': PERMIT O=:cr3Ett4 o#.ta5`4 4###:S R~FORT ~_
<br />- JR2I4NAI..- ` TaL- RAB
<br />~F~;~.; T _ rn,.u' REQUIREMENT. .,. .. - 'RTR AVG Y ;KG/,. ..
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICeniry under penalty of law that this tlocumant antl ell attachments ware TELEPHONE DATE
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<br />' ~/ ~-,~ !~ ~~ r+/ i ~~ ~ preparetl untler my tliracYion or supemsion in accortlance with a system tlesigned
<br />to assure Thal qualilred personnel properly gBlher antl evaluate the inlormallon
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<br />- submitletl. easetl on my ingwry of the parson or parsons who manage the system,
<br />- _ the Inbrmation
<br />or (hose parsons dnealy responsible br gathering the Inlormation ~
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<br />my SIGNATURE OF PRINCIPAL EXECUTIVE ~ ~ ~
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<br />TYPED OR PRINTED I am aware that Moe are signillfant penalties for submming salsa Inlormation,
<br />includin the ossbdi of fine antl im risonmem br knowln violations. OFFICER OR AUTNORRED AGENT NUMBER YEAR MQ DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONS (Helerence all adacnmenls oars)
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<br />EPA Form 33201 (REV 3/99) Previous a Itiohs•rriay be used. T IS IS A 4-PART FORM PAGE ~ OF
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