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PERMITTEE NAME/ADDRESS pnclude Facility Name/Lacotion jDij(erenr) <br />NAME _ <br />ADDRESS~t : ~ ,-~, , <br />. ~~1 _..... 'Y ~ ''' <br />.~ <br />FACILITY d • r, : „ .... '. l _ 5 , <br />LOCATION <br /> <br />NATIONAL POLLUTAN7 DISCHARGE ELIMINATION SYSTEM (NPDESJ <br />DISCHARGE MONITORING REPORT (OMR) <br />..•.. t.~r:'~' ~.t <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~? i TO ;l? ~ i <br />Form Approved. <br />OMB No. 2040-0004 <br />- 'r r ti 4L <br />' r~ ~ 1 1 1.: l i J ? :~. L k '1 <br />NOTE: Read Instructions before'CDfripleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br /> EX OF TYPE <br />PARAMETER <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS aNa"rSls <br />L \ ', :' i ~= : + ~ _ SAMPLE ~ ( .1) ~ ... . <br />/ , ,. ;, y MEASUREMENT <br />". U., '~ i li PERMIT O##'.fil## .,__ ' #it#### ###### rtat#Otjk r,.:t .; $l; a;LY 'AL <br />,. L~~"?' .. ;>.~ 79;, ;1E REQUIREMENT jB~Y lSAR "'~I=O ~ ~ ~ #:~C~: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT "' - _ ,r .; yy,. <br /> REQUIREMENT - - - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ ~~`~',~, <br />'~ 1 r xM~., <br /> REQUIREMENT .• r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ -l'tr- C: <br /> REQUIREMENT ; ` `~~+ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT "'~- <br /> REQUIREMENT - ~~"~~" <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ... " ''' ~k -" `' ~' "` ~ ~#~, •. <br /> REQUIREMENT ~ ~ - _ ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT " • - - <br />-- "'- <br />- " - .. <br />- _.. ... . <br /> REQUIREMENT ` .. - - - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICarbfy untler penally of law that Nis document and all attachments were TELEPHONE DATE <br />h s ~ <br />~( preparetl untler my direction or supervision in accordance wish a system tlesigned <br />/ ~ <br />~C Csr r to assure that qualified persormel propady gather end eveluaa me 1Mptmahpn <br />submihad. Bazed on my inquiry of the person or persons who manage the system, _ <br />~~ <br />~ <br />_- me Information <br />or those persons tlneQly responsible for gathering me information --' "' <br />= <br />/!/ ` I <br />i- jr , <br />submined Is, to Ino best of my knowledge and belief true, accurate, antl complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE O <br />~L <br />~.l -' - ~~` <br />~ r <br />~ <br />~=- <br /> <br />TYPED OR PRINTED 1 am aware that mere are signdicent penalties for submitting lafse Inormation, OFFICER OR AUTHORIZED AGENT A <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> Innudin the osslbill of M1ne antl im nsonment for knowin violations. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />. ,_ Tyr-. .. i.. LL .L (_ -:y~ ... .. .-, ;.., ..~t. r ,.~_,_ :.: ~_ ~ .. :-. `' ,. <br />r 1. 'v - <br />.~. I.a..[, '!, F,l: .. .~,c... .-_• r• .. ,. .,A:~_ ;Ni-.it .. ...', ~ ._.. is .. ,. ' <br />EP ~orrn 39261 ~(R 3/J~ `~revlbus~e~itiorislrnay be used. 0 ~ 5 U ~ / ? , t I , I THIS IS A 4-PART FORM PAGE _ OF • <br />