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PERMITTEE NAME/ADDRESS (!nclede Facilip• NamelLoeonon if O fferenQ <br />NAME _ . , yy t <br />ADDRESS _ , ,: ; ) _ ~ = y . <br />'."~ LY i i'•~' <br />FACILITY <br />LOCATION <br />y: .t - <br />NATIONAL POLLIJTAM DISCHARGE ELIMINATION SYSTEM MPDESJ Form ApprOVed. <br />DISCHARGE MONITORING REPORT (OMR) OMB No. 2040-0004 <br />T 1.)- <br />PERMIT NUMBER DISCHARGE NUMBER _ _ ~.( ~ ~ - .I <br />MONITORING PERIOD - - ~ - ='' ` Gn0 n ,. dA y ti <br />YEAR MO DAY YEAR MO DAY <br />FROM i '_ " TO -! i ~ i 1 ? ~ ;'. ~ '.: _ -. A ^ : '' y .. ~: ;: <br />NOTE: Read Instructions before~om~pleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br /> EX of TYPE <br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br />,- _ ~ .I ~i ~; It r 4 r :. SAMPLE - - .. ( '. I~ ... . ,... .. ... _ ... . <br />y i ~ :; :. c, MEASUREMENT <br /> <br />• ' J'~!^ i .i .. <br />PERMIT <br />#####Gr <br />~ .. <br />._ <br />tp#O4## <br />#atC### <br />##*f#'.s4 <br />.- - i <br />}S~k~,l' <br />;~~@'l <br />''L.j -'i ~-i; - '.L `. '' REQUIREMENT IBSY MA% '~,~- ' <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> REOUIREMENT ~ ~ ~ ~tr<"r' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ ~ ~~ '~ "~~~'~ ~ r <br /> REQUIREMENT ~ ,t. ~,,= ~.~; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ - ~ ~ '' ~,?"~~~ '~ -: <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ .~$ ~ ~ ~ . <br /> REQUIREMENT ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - .. <br />its <br />-~ <br />t <br />= ~' ~x <br />.fi'i .. . <br />P ~"" <br />'~k: <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - ,. ~ _ ,._ <br /> REQUIREMENT - - _ <br />NAMERITLE PRINCIPAL E%ECUTIVE OFFICER I Certity under penalty of law that this document antl all attachments were <br />i <br />i <br />tl <br />" TELEPHONE DATE <br />~ ~-/ ! _ ~q <br />EZ <br />~ <br />? m preparetl untlar my tliredian or supervision In accortlanca w <br />th a system tles <br />gne <br />to assure that quali/ed personnel properly gather and evaluate the information i <br />- <br />- <br />, <br />.7 ~ ~ J/ ! (.c-, <br />~ t S <br />~ . T <br /> submitted. Basetl on my inquiry of the person rn persons who menage the system, <br /> the information <br />or those persons dimcgy responsible for gathenng the iMOnnetlon <br /> <br />' J r <br />J 1- , <br />m <br />itt <br />kn <br />nl <br />e <br />d b <br />lief <br />tme <br />ccurate <br />and c <br />lete <br />d E <br />t <br />th <br />b <br />t <br />t <br />d <br />b <br />7 _ <br />~ <br />- 4 ~ <br />L <br />v <br />i j t <br />. p <br />e <br />, <br />, a <br />, <br />. <br />su <br />m <br />e <br />, <br />o <br />e <br />es <br />a <br />my <br />o <br />g <br />an <br />e <br />o SIGNATURE OF PRINCIPAL E%ECUTIVE CJ ; ( y L L~ <br />TYPED OR PRINTED I am aware that there ere signNcant penalties for submiding false informaton, OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> inciutli the ssit>;t of tine and rcn risonment for knowin violations. <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONS (Helerence all attacnmenrs nereJ <br />r 1. ~. ,~' <br />SPA dorm 332b~1 `(REG 3/J9 ~ revibus editions may be used. THIS IS A 4-PART FORM PAGE OF <br />