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PERMITTEE NAME/ADDRESS llnrfude <br />Fnrilily Nnme/LOrnlioR i( dif(errnN <br />NAME ~ , ~ ~ . <br />- t~-1~' i-e-:-'~-ir,r--.'-.r:-arii-rt i'.-- =1rT,;-' rn-ri.l'.- - - <br />ADDRESS . <br />-~}erer i-_Ts-_-_---_-_-.-_-,_ <br />DISCHARGE MONITORING REPORT i DURi <br />('-h~l I II~IYI <br />_^,11 r,. <br />PERMIT NUMBER ~ ~ ue[P <br />~ MONITORING PERIOD ~ <br />1 ::J :; <br />.I ,A Form.Approvetl. <br />` l - .r F I 'a ;,) OMB IJO. 2040-0004 <br />Appfoval ex fires 10-31-$4.; <br />~...-,~r~ r - <br />------------------------ YEAR MO DAY YEAR MO DAY ___ <br />LOCATION ___ <br />__ ---_ FROM ~ ~ TO - ,•. ~. <br />_ <br />_ <br />_ <br />NOTE: Read instructions before to-Sr lpletin9 this form <br />~ <br />. <br />L ' t- r'o-~u r']~: ~ 1 I ~~as) r'm'71 r;,eaal , .n~n r <br />+ 'I' .' • ;, ~ <br /> Ll CJ r,' Ihlls) QUANTITY OR LOADING (~ CarJ ORIp) QUALII V OR CONCENTRATION <br /> <br />PARAMETER <br />tln d?1 !iJ-611 <br />(t$-15) fJ?j 11 /iJ-h/) <br />NO. <br />EX FREOUENCv <br />OF <br />SAMPLE <br />TYPE <br />(7?-t7) ANALV Sis <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS (bla J) (r,~-ryRl l69-]01 <br /> SAMPLE :: :.::::: :.: :,::.=..: :; ,. <br />f ~ <br /> <br />MEASUREMENT <br />-~ t <br />', _ <br />` <br />it <br />/ <br />OOtJCO 1 L C PEP.MIT :F::J4`•>;:~ v'ri+lo:YFf: i O.J `a,':'t::}:i ~.O ~P <br />~KLY' ;3AU <br /> REQUIREMENT <br /> <br />~OLI~.°ia T(.lxl. 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THE Ih <br />Qf1MATIDN SL <br />BMIT <br />ED rF_RENJ AND BATED <br />ON MY INOURY OF THOSE WDi VIDUAL$ IMMEDIATELY RES°ONSIBIE FOR <br />OBTAINIpG TNF <br />INFCQMATiON I REDEYE THE SUBMITTED INFpRMATION IS <br />/~~ . <br />1 <br /> . <br />T9UE 4000RATE AND COMPLETE I AM 4WARE THAT THER[ 4RE <br />SIGhiFICANT PENALTES FOR S <br />BMITTING FALSE INFORMATIO <br />INC <br />NG <br />D I /~[_~ <br />-- <br /> I <br />U <br />N. <br />LU <br />iHE POBSBIU*v OF FwE ANO IMRRISONMENT BEE 16 USG 6 IWI AND <br />nd[r Ihne n <br />33 UBC f 1319 (ft <br />alhe <br />(ul[ <br />' <br />[l <br />d <br />Ones <br />to SIGNATURE OF PRNCIPA "- XECUTIVE <br />~ <br />• <br /> n <br />s u <br />a <br />s mey <br />u <br />e <br />uy <br />10 <br />- <br />S <br />00 T <br />C <br />T A <br />TYPED OR PRINTED If1.0 <br />anJ or ma vmum impnsonmcnr u( buunn ~ mun: hr and S ~,, <br />arsI OFFI <br />ER OR AU <br />HORIZED AGEN Op NUMBER YEAR MO DAY <br />COMMENT ANO EXPLANATION OF ANT VIOLATIONS fHel[rCOC[ all a!laCflmCrlts OtlrCf <br />1-TI`IE RNA.L it::~aU l.i 1'if J:Ci'dG l0!'T-A?!. f':I~ iL., D:: r.l.'.r-GL./' P:fIL` .IF'.(:i', Mi'..-;.., :O1'I. 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