|
PERMITTEE NAME/ADDRESS (Include
<br />Facility Name/Location i( di(lenrml
<br />NAME _ ~-±-F"i--~' K=J-R-:~~ ~-i-=r-F Y- i~?r:-.~-i T.~ri- - -
<br />ADDRESS-.
<br />- - - -2-0-s}9{ --E:'3~1[o ii :-Y-'L--j'r-~ ---[~ J;'~i:-1--1!r- - -
<br />FACILITY _______ _ __ _ ____
<br />LOCATION ___________________
<br />N PTIONPL POLLUTn NT DISGNq RGE Eumm~ nun a r a. c . , . ~... _,..
<br />DISCHARGE MONITORING REPORT ! OdIRJ
<br />Il-Inl l17-141
<br />
<br /> r
<br /> PERMIT NUM6ER o sc
<br /> MONITORING PERIOD
<br /> YEAR MO DAYS- EAR MO DAY
<br />FRO M ~ TO - p,
<br />
<br /> /)A. )J: I?Jn 11 ,li-li1 I)6-)71 /)v-~91 /li1. 111
<br />i 1 :r .1 ~•.
<br />Fora Approved.
<br />i L) .'.t ;L 4' I I
<br />- F, ~ .; OMB IJo. 2040-0004
<br />a '_ pD
<br />[; F' S C I!i :i r~P,fovalR>~i{eJs„10;311-94
<br />~~NOTE: Read instructions before LcD7rlpleting this form.
<br /> (i GIJ fiulYJ QUANTITY OR LOADING (J CaFd Only) OUA LITY OR CONCENTRATION
<br />
<br />PARAMETER
<br />Ln-5]) (?Lbl)
<br />l7F-1f1 (fib ~?JI (Sa-61)
<br />NO.
<br />E% FREOUENGv
<br />OF
<br />SAMPLE
<br />TYPE
<br />(J?-J7) AmALV SS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS IL1-0il lhJ 54 fh4 )Ol
<br />P{{ SAMPLE
<br />.. :.:.: .: .:.
<br />. ..... ..
<br />. . .. :..
<br />!: i:!: !: !: C:
<br />. . . . .
<br />..:. ..... ....~.
<br />.... ... .. ..
<br />. .
<br />
<br />I
<br />~
<br />;'~
<br /> MEASUREMENT _
<br />UOuVO L O V PEP.MIT f:.',:::[:.:X[:: [R :`.'.:Lav b.5 •:: 4'. :;::::. •V St.i.Y i3AJ
<br /> REQUIREMENT
<br />:' IL` Ur 11 4T A qtly -..I
<br />JJLI US
<br />TUT lL SAMPLE ~ :... p .. ~ ! 4'
<br />, MEASUREMENT
<br />SUSPF:NDcD
<br />
<br />Gu53U 1 G V 'PERMIT ;: ,: JCui~k >:[Q:,[livfi C 13:~:~ -'.[r'v;T ;: f;: J~) %L1 I!~t. ~'~ 71~~{
<br /> REQUIREMENT
<br />
<br />SOLIU~
<br />S6T'i'LdA6L~ SAMPLE ::4:7::y: ': Y:[(-.':~v,`. ~:f:::p^:? =
<br />~~
<br />, MEASUREMENT \
<br />-
<br />1
<br />00545 Z <] .1 PERMIT ,. :~Y.q4 i:[ L'-''c :Y O:`•:' [; t,: (: ~: .': [i [F ia,: 'F "'P
<br />~ 1'O[1 ,n L'^
<br />R'r'_pu. 4
<br />s.iCE f
<br />rRA.1
<br /> REQUIREMENT
<br />
<br />UIL AND GRLrJi SAMPLE ....:[fF fF t;".
<br />y : [11Y :[+: :....i ~:~ ~: :f,..':: :': ~ 1'1~
<br /> MEASUREMENT
<br />FiitUN BX I'R-.:itAY tI3T:J
<br />.
<br />OGSbb 1 Ll J PERMIT r'v~+':IF~F YS :::3,[.',a=Yi ~;[:, ::[;:;:z~:[; ~::a::x;;: 10 UNTT
<br />:+ '~F
<br />6
<br /> REQUIREMENT . .
<br />'
<br />C^ T - a;p - J~C)
<br />I a~ ti
<br />TJT;, L `' [7 +[ %:'::1: ::: r. :;: !: {<:: :::;[::1 ;=':[ ~ 1 y
<br />, MEASUREMENT
<br />(AS F~)
<br />V1UY5 % U 'J PERMIT ::JLffLTR +j'.:v,:ie:[ ff[FvIF[;:i< j. ~ 7.U J:t~.F.~ ~RA:i
<br /> REQUIREMENT
<br />
<br />FLY., IN [Q:IJUI'1 [1^ SAMPLE ~ Vj~ ::~:;::::~:: :.:...:...
<br />~
<br />~
<br /> MEASUREMENT D
<br />TdHU CkEA'! h~Sl'r'
<br />aG' t
<br />_
<br />
<br />50050 _ J G
<br />PERMIT• p
<br />RL:{'OftT
<br />Y. F.[~08T
<br />+~a~i=;k;[;f
<br />. .•'.:r:;r:,[
<br />,::~:;:[~., [
<br />:,^•;::::
<br />EEL'/
<br />1ISTS;t
<br /> REQUIREMENT .
<br />G' O 1 l ~ T !:IS': .
<br />SOLIDS, ':01'AL SAMPLE ..:t,`.I`~: :Y~1:`.:{:: ,., ~., ~ ll)
<br /> MEASUREMENT
<br />DISSOLYEJ
<br />
<br />7GJ?95 1 J PERMIT (: +f44/Y+:: #'[#C'%F ' :}':i: K[[kX[:iLX~•'.[ :{LFOAT OPTZUNF.:. '.TREY 'RAi3
<br /> REQUIREMENT
<br />I I I: - 11"' y: I
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER i CERTIFY UNDER PENALTY OF LAw THAT I HgvE PERSONALLr E%AMwEp
<br />PND AM FgMILIPR WITH TriE INFORMAT
<br />ON SUB
<br />ITTED HEREI
<br />ANG BPSEU TELEPHONE D A T E
<br /> I
<br />M
<br />N:
<br />ON MY wOUWV OF TI-IOSE INDIVIDUALS IMMEDIATELY RESPONSBLE FOH /~~
<br />`
<br />/~
<br />11 ` _ `r_
<br />O
<br />J
<br />~ YW'~ INI
<br />FO NM
<br />ATI0
<br />P
<br />~TD
<br />U
<br />E
<br />F
<br />EVP
<br />~
<br />N
<br />~ ~
<br />~
<br />•
<br />-
<br />V D
<br />nI
<br />T
<br />RUE
<br />AC ORATE
<br />AM
<br />PWARE
<br />HAT
<br />HERE
<br />4RF
<br />0
<br />LETE
<br />T
<br />$IGNIF ICANT PENALTIES FOR SUBMITTING FALSE INFORMATIQN INC'
<br />UDNt
<br /> .
<br />L
<br />THE ROSSIB1VTr OF FmE grvD IMRRIwNMENi SEE 1B usC 4 Io01 PND
<br />..:
<br />,
<br />3] US
<br />C S 1319 (Ponvlues unuer nm.c aumrcs ne. ,n-Jr
<br />'c .:m i
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />•
<br />TYPED OR PRINTE .
<br />e
<br />.
<br />n ..
<br />f IOLO(J JnJ nr nv amum unnrisnnmem of howrrn 6 monJO -.nJ f 1c.lrs J OFFICER OR AUTHORIZED AGENT C NUM E YEAR M DA
<br />COMMtNI ANU C.[YLANAIIVN Ve AIVr VIV LAIIV IV> IRl'I(I[IICC CII JIIJf /IIIILIIIf II[ICl
<br />T55 4 T0T.1L IHJS ..Il1T:, +I LL .'i, :R.:V"cD A`, .. .'fiL....~L~ ,,.i!?7:. ..t [ A. r' }•ng =7 ~ !r' i'~_.f' Y.I:-
<br />$:.. I. A. .:, :., i'!, ~.~' 11' ,1.11 c.~i;~•~1 .,. Q:I°HLY _Aa.~L.:, I.', .: 5':'O:: ~r:-i r ,-.. -. i, _ tii.I {.
<br />EPA FO(IR 3320•t (Rev. g-86) P/eVIDU$ edl(10/IS may b2 USed. IREPL ACES EPA FORM T-a0 WHICH MAY NOT BE USED.1 PAGE OF
<br />.~~[_. f/•:J Ali... 3-!''_.. ;.
<br />
|