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PERMITTEE NAME/ADDRESS(/nclude Fanliry NamrlLocanon ijDiJ/eent) NATIONAL POLLUTAN7 DISCHARGE ELIMINATION SYSTEM (NPOES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESSt. :i .-~..J _l .I •.p .. .t -tr,. ~,. ~-+~. <br />y ~ J / : ~ - ~, r.: v t ~ . ~t l PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY •~ ~ ' `~ r - ~ ~ t ' MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM J i '~ i ~') TO i i 3 ', <br />.~F + e• <br />Form Approved. <br />OMB No. 2040-0004 <br />T J '. <br />zu hcr. ,as'] <br />f NOTE: Read Instructions beto~e~nipleting~this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER EX OF TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br />.., r. C .. .: u ... ~ r SAMPLE .... ~ '.i) .-. .. - .. .. <br />Y '. i J r• L MEASUREMENT <br />• l ~ ^ 1 ) J PERMIT ##X.#0gr0 ,~ - ;_ ]. .###CI## Sa###$`+ ##~#dr YS . <br />~'), '+.~ p ;-, ; 4., Jt_ REQUIREMENT - 11152 MxX =;~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT' <br />- ., - = <br />- .. - _- .- .. , - .. <br />- <br />,,•: <br />'r , <br />++:; ~ -. <br /> REQUIREMENT ° . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - ,:j: i- , <br /> REQUIREMENT - ~< <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ - <br />- <br /> REQUIREMENT - ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ -~` <br />~ ~~ <br /> REQUIREMENT y;-s, <br /> SAMPLE <br /> MEASUREMENT <br /> ~. PERMIT '' .''sn' ";. "'" d° ,~ . ~ T.. .' ;~_ n _~ J-~ - , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />-'- - <br />- ~~ <br />~ - ~ <br />-~ ... ; °, sar" ., . <br /> REQUIREMENT - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICeniry under penalry of law that this document and all attachments were <br />d <br />i <br />i TELEPHONE DATE <br /> <br />~ prepared un <br />er my tlirection or supems <br />on <br />n accortlance with a sysem tles~gned <br />j(Q~~L •~ ,~ to assure matqual+fed personnel properly gatharantl evaluate the rdom+ahon <br /> aubmirletl. Basetl on my inquiry W the person or persona who manage the system, <br />'- <br />/- or Nose persons direttly responsible for gathering the lnlonnalion <br />the inbrmation <br />/ <br />/ <br />_ r i / <br />C , <br />ubmined Is <br />to the be <br />t <br />f m <br />k <br />l <br />e and belief <br />true <br />a <br />r <br />nd <br />lete <br />d <br />c <br />t <br />m ~ <br />- <br />' 6 <br />!- . <br />y <br />, <br />, <br />. <br />s <br />s <br />o <br />now <br />e <br />g <br />c <br />u <br />a <br />e, a <br />co <br />p SIGNATURE OF PRINCIPAL EXECUTIVE y ~ J c.>, <br />1i <br />y ?. OI O Z <br /> <br />TYPED OR PRINTED I am aware Thal mere are signifcam penalties for subm+ning take inbrmation. <br />inclutlm the ssibili otfne and im risonmant for knovrin violations. OFFICER OR AUTHORIZED AGENT A <br />DE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />- - ~ TJCd.. [. ....~.. .l .... _. ", ~ - ,.. - ... L-. L1: LL'1 a - . .._.._ ~~ :=i.;v .. ;.CIP .:Gc . - <br />, .. I. S•L, r'; 'J, i,~l{ y` .. :;4.-. `IL ;r. '..Q~.. P-: R'"I'-~-_.. I. ~. i.c ,~!, 1: 1. .'L°, , <br />i.. .. . <br />EPA Foim 33200.1 (REV 3 ~)` Previous editions may be used. THIS IS A 4-PART FORM PAGE OF <br />