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PERMITTEE NAME/ADDRESS Qndude Facirily NameJLocanon IUi$erenr <br />NAME <br />.LIJ 'I77•+''AI'd ;; •.`..t ~7, Ian. <br />ADDRESS. ~ -. y '. ~ ~, ~ .. I '~ <br />FACILITY - " ' L f -" <br />LOCATION <br />f <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPOES) Form AppfOVed. ,~ <br />DISCHARGE MONITORING REPORT (DMR) OMB NO. 2040-0004 <br />•-~;~, <br />PERMIT NUMBER DISCHARGE NUMBER _ <br />r' i ' ~ -... „ .. <br />,, <br />`' ' ~ MONITORING PERIOD ~ ~~ ' `~ -• :• i 'r';:v ii : f) ~' 4 j H <br />YEAR MO DAY YEAR MO DAY <br />FROM .I TO ')i _ s i ~ = J .' ~.~.lAad' ~` `'' <br />NOTE: Read Instructions before co plating 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 ANALYSES <br />I SAMPLE <br />. <br />T' "~ ~` <br />... <br />~ ~ ~ ( i~~ <br /> MEASUREMENT <br />J . t i i t PERMIT .###Of# 4###12# ~~ b.3 ,. ##xi+C#0 3.0 t:E4( <br />r i. ,;. LL. ..!.~. ~, YAL!;; REQUIREMENT ~ :+I ttI MUlf RARIf4U .' 5U " ~~ ••..- <br />., ., i J 1, "J: ki, SAMPLE .. .- . '.a:: ~k ;: G#-'.1 :~ ( 1'~~ <br />.. _ MEASUREMENT <br />!/ l 1 !, PERMIT Xp#ile 4,Jrir r,:.>, :~ ~~:_: ##`S44'ltc 35 :~., ,~ •.,: ". Yt7 .". Rr.` ,... <br />1 ~. <br />..) ~. I' 1.• ..J r REQUIREMENT - ~ 3~~~~ APG nAZ Li :7Y ~I1. 1i'j'!~ <br />:.: ;i ; ~ ~ i~ 1' C L .' ` L ~. SAMPLE .. .. , . . '.4 ;. ... ( <br />i <br /> MEASUREMENT _ <br />~ -, 1 ~ J <br />~ PERMIT #o C4rT# #AAtLe## ... aXA .,.. !~~ .~: •R,E pORT - $'F. $ry'I ~A$ <br />i:'.'.J~ n ,,7~_ yaLU, REQUIREMENT k~. ;,;:. ' 3UUA AY: rx .`/ -. ,~ fi - <br />,.. r :,z -'.A: ° SAMPLE .... :. ,.': is ~: Pb##:b ~ ... .. ( iy~ i <br /> MEASUREMENT <br />~.,~•, i J t) PERMIT #G#fi3r tL ##fi### #4tRS tt#>A ~xafi~:LAr lif ,. ~'" M~ O1fT ~'I+. <br />=' L ~` ,. ;7. ~ 541.1:~ REQUIREMENT ~ IHS'f "AJ :/L--~ . <br />I ~:., id", AI. SAMPLE .. _ ~ .. t: ~::.:::-+. ( 19~ :. <br />(.•,~ ;'~;) MEASUREMENT <br />t i ) .. 'PERMIt 7e##a#4• ,xraa#¢ +.;.. .fgF:F..;4 ,t 3.0',.~ ~ G.0 <br />~ ~:~: <br />. <br />' - 1' .i _ = 'l ?. i ,; : REQUIREMENT ~ r ~.<~ - A Y " O A <br />' ,1G L `"' <br />_.L'a i:v i Y.-'.1! SAMPLE ( ;i.i~ ..:r: ,::4', Cr#:.. .., rxp###~ <br />[ :~'.; q ; '~ , ~ i. ~ ~ MEASUREMENT <br />, • J~ I v PERMIT REPJ~T ;" <br />~ <br />- <br />~ - <br />r~ t' i. 1' - ;. 7 ~ ~ 7 t L " e <br />J REQUIREMENT 3 0 D A A Y ~;. ",k" Li." MI Y r, r D _ :y <br />- ~ <br />.. <br />~ ~ ~' •: <br />r .. L.'3, f'.)1 y+- SAMPLE ~ ... 'r :P :t {: t't ~.~ ( <br />t r'~ <br />L 7 ; ~~ MEASUREMENT <br />1,, ..1 I i - PERMIT G:k Sx#.:r #7c##+YC t ~ .. u+R#~#7i RBPD RT ~PTI ~lI„-~ <br />.- <br />~ - $~L,~-'~: <br />`r1. ,'-'•~:' :,'J_i: /!L REQUIREMENT ~ - '~$7R A 3~ R ~( '~'/i. - <br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I Certify under penalry of law thaz Nis document and eX attachmems were <br />d <br />d <br />l <br />i <br />i <br />i <br />h <br />i <br />d <br />d <br />d <br />d TELEPHONE DATE <br />.Id <br />7 <br />~ <br />~ ~ <br />S L L i ~- G <br />~ <br />r prepare <br />un <br />er my <br />aec <br />ion or eupems <br />on <br />n accor <br />ance w <br />a system <br />es <br />gne <br />t <br />to eswre lhat qualified personnel properly gather and evaluate the information <br />, <br />, <br />( <br />- <br />. <br />J submmod. Basetl on myinquiry of Ne person or persons who manage the system. <br />' <br />- tho iribrmation <br />or [nose persons deecay responsible for gathering the inronnation <br />L <br />1'Y <br />~ / / ; / , <br />s <br />bm <br />tted i <br />t <br />th <br />be <br />t of m <br />kno-Med <br />e and ballet <br />tmo <br />a <br />curate <br />and com <br />lete ~ ~ <br />~ 7 <br />' <br />" <br />i <br />, / i <br />y <br />g <br />, <br />, <br />p <br />. <br />u <br />s . <br />o <br />e <br />s <br />, <br />c <br />lti <br />I <br />th <br />th <br />i <br />m <br />f <br />tti <br />t <br />k <br />i <br />b <br />~b SIGNATURE OF PRINCIPAI EXECUTIVE - ~ <br />% < <br />~ ( G4 ~, <br />TYPED OR PRINTED am av/are <br />ere are s <br />gn <br />cam pena <br />es <br />or su <br />mi <br />ng <br />e <br />rtnat <br />on, <br />at <br />a <br />include Ins ssibili aline and im risonment br knowin notations. OFFICER OR AUTHORIZED AGENT AR <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />. 1. .l, 'r :'. ., .. :`~.. ~ -. ~ ., ~ ,- ,..: .. ..!.', u i. .. ". - .. <br />EPA Form 3320.1 (REV 3/99 ~ Previous editions may be used ( ~ _. ~ .THIS IS•A 4-PART FORM PAGE OF <br />+. , <br />