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P[RMITT[[ NAM [IADDR[tt (jncfude <br />FtN/ry Nine/lncatbA IJdIJJerrnfJ <br />~s--PITT58t1B6~L ~' Z(1 fiAY-CIIA i. ~iIALHG.__- <br />~ooR[n~D.L~L(~! p./L~/N~.*E----I---G-n Y-~--T G-- <br />~~ ~~R3iY-hiV~ yiQ-H-µY--~~'T ~~MYI~-J.-s-i~- <br />---~A~C sB.E E1C--_ _ _ _ _~ ~~~ <br />-Aelurv <br />---------------- <br />LOCATION <br />NwnonwL rouurwnr DncNA Rat euMlHwnoN tnrtM lNPDE51 <br />DISCHARGE MONITORING REPORT lOMR1 <br />1~j6 1~ <br />/lRMIT NUMBER RI•c.Iwwat RVM•tw <br />MONITORING PERIOD <br />YEAR MO DAV Y[AR MO DAY <br />PROM TO <br />11011/ 11113/ l11~1 1 /16~ / /181 / ! l <br />:'1 I N U h Form Approved. <br />(5 U & R H W QMB Alg.(~440-0004. <br />fl- I A T E ~pphoval expires 6-30-91. <br />SURFACE RUNOFF TRCUT CRN <br />'~'~~+ NU DISCHARGE YtC<K• <br />NOTE: peed inetruetione before ~omp~atinq this form. <br /> (3 Card Only) OU ANTITY OR LOADING (r Cord Only) DUALITY OR CONCENTRATION FR EOU ENCY <br />BAM PLE <br />PARAM [T[R (IdJ3) (Sifil) ~ (ie-r!) (16J3) (!1-Q!) NO. aF TYPE <br />(31-37) EX ANwlrelt <br /> AVERAGE MAXIMUM UNITE MINIMUM AV !RAGE MAXIMUM UNITE 67fi3) (6rfie) (69-70) <br />GIL AND GREASE sAMPLE noaloa ( 94) u~a~ol ~~~Pa caaaa <br />Y I S U A L MEABUREMENT <br />b40G6 i 0 0 ~~I'tRwlig>~ <br /> <br />"e9mREM e <br />T• ~iR~ <br />~ Y~~+k'OF;~#et ~ $ <br />affi°{i':a~~~~~~ <br />~ <br />3+ <br />YE5=1 ",~ ~s <br />~..a"~~~~c~a <br />' <br />~ x <br />ffi$~4~~I~s -na %~ <br />~~>~-~'O~a <br />4#{rY e~~ <br />j~.~~ ~' `~ <br />~ ~~ <br /> N ~'.~ ~~ ~`I >~a,~~~ ~ .. <br />~ _ ~~i~~'~.~ 1 <br />~x. s~ ~:~'~$~A~s~g~ ~:tea -~"gym-~ ~~~& ~~» n' °s~,~ ~'~ ~ ~'s~~~. <br /> SAMPLE <br /> MEASUREMENT <br /> ~ag ~ <br />x«~ <br />~'~ ®` <br />~'~~$'A'~ ~~ <br />~~g~~s~~ : <br />~i <br />~a~cer <br />8~~~ ~ <br /># <br />~~ ' ~' <br />.~ <br />~~~?~ <br /> R[qU R[MHN'[ <br />3 I <br />~ <br />® <br />~° <br />~~ <br />~3 ~ <br />k <br />~ <br />~''~` <br />~ ~ <br />~& <br />~i ~ <br />~ <br />~ <br />fa <br />i <br />~ tt~ <br />>88 <br />~~w ~ <br />' <br />~` <br />~ II,~,~e <br />" '~~i q <br />~ <br />j <br />~ <br /> .' a& <br />~ s a a~x~~ <br />~ <br />4~ <br />„ «.~~ <br />~~ <br />F <br />, .~~ <br /><...~~a <br />~ ~$S•w <br />.T~di , ~ <br />~` <br />~.£w <br />$~" .$ <br />~se, >~ ,}rr. . <br />~~~"°A>t <br /> SAMPLE <br /> M EABUREMEHT <br /> ~~~PErIMit ~~ a~ x )"R~z~.~~~ <br />~` a ~ffi~~p~v.:~. _,~~ ~ <br />. <br />' <br />2 ~`~.~"e'~~3~_~'~. <br />. ~~ <br />%~ <br />~9 <br />'~"- .a> ~~~ '°. S"g <br />e <br />~~ <br />x <br />~ ~ffi.°~~`~ °~~ <br />+~ <br />~s ~ <br />` <br />~ ~8 g; <br />°` ~ ~ ~" <br />~~ <br /> °NS~QEIR N.~pT <br />~ ~ <br />~ ~m°am~ <br />° <br />~ ~ <br />~ <br />~,. <br />"ffi <br />° <br />~ <br />~ ~, <br />y <br />,a <br />~ ~ <br />~ <br />. <br />~ <br />~~`~' <br />~ ~ <br />~~g <br />~ <br />f <br />~ <br />~ <br />~ ~~.~ <br />~ :~?. <br />~~ '~ <br /> ~~ ' °a <br />,_ k %s ~...~~~' + <br />~ <br />~ ' .~ <br />~' <br />a ~~ <br />a <br />- ~ffi~m~Yk ` <br />~~s~. <br />~~~s~ ~ ~ <br />~^ <br />kle, g , <br />~< ~,.n . a:~•~~ <br /> SAMPLE <br />q~ ~ MEA <br />BU REMENT <br />.r yy <br />,~YEb4 <br />ncM irY a <br />a~ z ~~,'~~ $~$ n®~~„~n~~~ yew <br />` ~Y~ ~e ~~~g ~`~~~ ~'~~~~~~~ag~~.:s <br />' ~~~~p.~a ,~ ~~~~~ ~.~,~ ~~ <br />~ ~ '~~° ~> <br /> Y <br />3 <br />~' y m x ~ ~ <br />:s a ~.•m.~~ B~~ ~ ~ ~~ sAg~s <br />~~.~i"y ~d'~~~~'~ .g !Da ~~>~'>~D ~wy <br />~ei ~_aa~ .~_~ Y'.~®& a v~~~~ '~~'$ $~ ~T .:.~#. <br /> SAMPLE <br />. <br /> MEABUREMENT <br /> <br />-~,.. ~.~,~ re <br />~RMIT€e <br />~ <br />I <br />' 4o- ~0"~%~ i-v <br />rnr r`3a ~ ~ <br />~ ~~~~~ ~ <br />8~" e <br />~ <br />~ ~"' B"a6 g:~ .~~ <br />~~ ~8 <br />~~ 4 q ~~ q°°~: <br />®_~~ r~'d <br />~ <br />~ 8a ~ P~~.B ®ffi'n <br />~~~~, ~_~' A. < <br />~ <br />~~x <br />3 ¢w+~ <br />~< <br />a- "}R' F' <br />'~*~ ~'~"' ($.. ., <br />»' <br />' <br /> E <br />TtlLREN6NT <br />R ?os A~9S <br />'~~ ~~~' <br />~• ~~. 8 , <br />. <br />&~ m <br />s ~ . ?. <br /> <br /> SAMPLE <br /> MEABUREMENT <br /> p <br />Z J'x <br />x <br />x a ~ " ~ <br />~' ~ ~ <br />~ ~ , <br />~ <br /> CNT~ <br />~ <br />E0Uh1F[A ~ <br />, <br />a , <br />~ ~}J yy ,~~' a <br />, <br />~g ~ <br />.~ <br />~~ pa' t ~ a~ <br /> SAMPLE <br /> MEASUREMENT <br /> aa[ <br />W RE N Sf °' a ....~~ I ~ ~ ~~ .~ f.ffi ~~P~ <br />~~. ~~t <br />A <br />~& <br />~ <br />~` '~. ~ <br />~ ~ <br />~~~ <br /> Q <br />'° K[ <br />. <br />. y <br />a ~ <br />S. <br />~E <br />~ '" ~~ <br />~ ~~~-.3>)~' ~ <br />LB& ~ <br />~ <br />~ <br />!,, <br />~~ <br />~ <br />~ <br />" ~ ~.o- <br />~' ~ <br />/ . <br /> rn_ •Y. <br />T + <br />® <br />.~, ~ <br />,g <br />. & .a ~. ~x . <br />, <br />i'.~~ <br />~ ~• i~i ~ • <br />NAM[/TITLE PRINCIPAL E%[CUTIV! OFFICER 1 C[RTrv UHDFR PFMALTY OF LAW THAT I HAY[ KRSONALLY tEAMINCO <br />ANO AM FAMILIAR M1TN TN[ INFOPMATIdi SUBMITTED HEREIN <br />AND BASED T[LEPNONE D A T C <br />r <br />~,~. ~LJ .JV . <br />ON MV INOl11RY OF TMO$[ INDVIDUALS IMM[dAT[LY RESPONSIBLE FOR <br />OBrAINdG THE MFdIMATq`Y I B[LI[V[ THE SUBMITTED MFORMATION /1 /~ <br />/~ <br />// y <br /> 5 TRUC ACCUPeTC ANO COMPLETE I rM AWARE THAT TMERF r.RC SIG . <br />~T <br /> NIFICAHT PENALTIES FOR SUBAITTING FALSC INFORMITION INCLUDING I <br />/ <br /> <br />m A aE SUPT. <br />.HL P0551BILITT Or rINE AHO IMPN60MM[MT SEE IB uSC 1 1001 AHD <br />810NATUR <br />OF <br />RINCIP <br />L <br />X <br />I '']r^~•i <br />r3 ~y r] <br />, <br />~,\ <br />~- (T <br />~ <br />~ <br /> ]]usC A 1T9 <br />IAn•hv. IIMr. rArr r•mr.. n nrld• Ln•. uy r., bgnrl P <br />E <br />A <br />E <br />ECUT <br />VE J <br />v ( <br />TYPED OR PRINTED . <br />aid ~~•ma+~m.m lnlP.Iiumm•.n .~/A.r•wntm.InrA. end.5 .nr.I OFFICER OR AUTHORIZED AGENT A NUMBER YEAR MO DAY <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS IR•Jrrrnrr Pll urruchmrnrl hrrr) <br />ONE-TINE ANALYSIS kEQUIRED AT FIRST DISCHARGE CONTAINING f"INE DkAINAGE/5?GILS SFSING 'I:T~-SEE CJUB. TSS E <br />TOTAL~IRON LZ!lITS WILL AE NAIVECF AND SETTLEABLE SOLIDS LIflIT' APPLIED FOR <=1GYR, .~uHn FSr.CIi' °VENT-SEE <br />E PdTT ) ~' rt ( E ~ R T s [ .M i 1 • PAac oP <br />' ~ Ilrlilrlf inns'.. ;c_T )'1 .. <br />