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PERMITTEE NAME/ADDRESS Ilnrludr <br />Faailiry Namr/Loaalion i! di!lerrnrl <br />NAME <br />ADDRESS.. <br />----311-!c-c '^: ~T~-------='~---:~i->-7 <br />FACILITY <br />LOCATION <br />NATIONAL PpLLUTq NT 015CMARGE ELIMINATION SYSTEM (iV VUGS / <br />DISCHARGE MONITORING REPORT r nM11RI <br />('-161 (17-191 <br /> <br /> <br /> PERMIT NUMBER <br /> MONITORING PERIOD <br /> YEAR MO DAY YEAR MO DAY <br />FROM TO ; <br />c <br /> ~ ., J' V= / <br />l O J J L <br /> r'0-111 r'1.1i1 r'J-1t1 rJh~171 I'.P-'91 r:0-ill <br />:. ... <br />i• J.. Form ~(ggtoved. <br />{ ~' ' `i ~' 1~ [~ 01418 No. (2040-0004 <br />- Fin6I- 9g <br />pppRloyal,~xP fes, 10-13 ~ {4 <br />.i7.: 'r'nC~;. .''1:11). . <br />...:. .Iu .~~~., in:;;~ YY II .... <br />~~NOTE: Read instructions before Cdthpleting~this form. <br /> l l OUA NTITY OR LOADING <br />(~ Cdrd Onl r1 OUA LITY OR CONCENTRATION <br />(J (';1rd Onl <br /> <br />PARAMETER , <br />Nnd.il rJJ-hll , <br />IJS-J.~1 Nh~T;/ (:J-p// <br />NO. <br />EX FREOUENCr <br />DF <br />SAMPLE <br />TYPE <br />(.7?-771 angySl$ <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (61nb (6Jd P) f6V 1~1 <br />C,IL A1~J vl'. -. i` SAMPLE ..:...' ~ ~ ... - <br /> MEASUREMENT <br />VISU <br />iL <br />. <br />r311 .J FJ 11 I - <br />- PEP.MIT .'::t >:. :. _ .. ... .... .'..t. '_~{ '.1 :%O ni. <br /> REQUIREMENT <br />- 1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERnFr uNOER PENALTY of Lqw TI-IgT I LAME PERSOrvALLr Ex AMINED <br />T <br />TT <br />'~ TELEPHONE D A T E <br /> A.VD AM Fq AI LIiR 41 <br />N THE NFORNA <br />~ SLB\I <br />ED NEPE11 AAC BASED <br /> ON Mr INOUIRV OF THOSE INOI VIDUeLS IMMEOItTELV RESPONSIBLE FOR . <br />w <br />1 <br />~ OBTAINING TFE INFORMATION I BELIE <br />E THE $VBMITTED INFORMATION I$ <br />- <br />- <br />Uv~ <br />U ` I <br />TgUE ACCUR4TE AND COMPLETE AM AWARE THAT THERE ARE <br />GNIFICArv <br />BMITTII'IG FALSE <br />NFORMATION <br />PEN <br />TIES FOR B <br />NC <br />DING <br />B ~ _ y'- ' /~ ~ <br /> I <br />AL <br />I <br />I <br />T <br />U <br />LU <br />THE P0551BILITV OF FINE AND IMPRISONMENT SEE IB U.BC 4 1001 AND SIGNATURE OF PRINCIPAL E%ECUTIVE <br /> 33 US <br />C 4 1319 IP~nJI(i[3 under !ll[s[ 1(Jlul[S nIJS' In[IYJ[ lilies u <br />l Ir <br />TYPED OR PRINTED . <br />. <br />SI0~00 and nr nn llmum Impnsrnmenl u! hnwv[n 6 mnnrb.~and ~ I'ur.) OFFICER OR AUTHORIZED AGENT A` N MBE Y AR MO D Y <br /> OD <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS fKrl[r[nr[ ell dIW[bmenls here/ <br />T~:+ ii TUi'hL Ii:.J\ Li1I':~ eCLL 'S F: rAIViiD, A. :, ..I r:1'':LcSJLr; 50LI~:i i.IJl~f ;,I=`Lic:D f'J^. <=1i?~-.[.'.4.1~< ..F,!'i" ..'!2!IP- <br />5d.- 1. d. 2a -'~ Ire 'r':i!: !!.;;UIi,F.I". !..:i~. '~K'Ri,Y ~!1tLllia i1+,iC:UC:lri.`l~-I.C.I~ ... :(III. <br />I:dl(IO115 mdy bC usBd. (REPLACES EPA FORM T-d0 WHICH MAY NOT BE USED.1 PAGE OF <br />