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PERMITTEE NAME/ADDRESS R+eLrsrFrdiryNw/Loe+no+dDl6w.llp <br />NAME ~ I <br />ADDRESS ~~ ~ f ~~ ~ - ~ <br />FACILITY - <br />LOCATION • • <br />NATIONAL POLLUTMT DISCHMOE ELIMINATON BYSfEM /NPDES/ Form Approved. <br />DISCHAROE'MONITORINO REPORT DMRI ~ ' "~' OMB No. 2040.0004 <br />1.16 /7-19 ' <br />~ ; Approval. ezplree 05.31-98 <br />PERMIT NUMBER DIBCHMOE NUMBER - - <br />MONITORING PERIOD <br />YEAR MO DA Y A MO DAY , <br />' FROM ~ TO ~ ~ ~ ~ ~ ~ ' ' ~ ~ I V <br />raaau na-a31 11~-asi Ise-2n n9-a9/ lsasu NOTE: Rnd Irnwctlona bdon eomPbtlnp th4 form. <br />PARAMETER /9 Grd On/YI QUANTITY OR LOADING I<brd On/yl QUANTITY OR CONCENTRATION ND FRFOUENCY SAMPLE <br />r 1663 61611 199-{6 0663 61-b1 OF <br />~~ ea EX MALras TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS let•sol I64s81 169-101 <br /> SAMPLE ~ ~ ~ ~' ~ ~ - . <br /> MEASUREMENT <br />. - PERMIT ......y,...,: ,:. s. , ~~ <br />,'. <br />~ <br /> REQUIREMENT. ~ ~. ~ •. r ~ :.e A ;. ~- ~. •~: n .. <br />. ' SAMPLE ~ .. ~ ~ { <br /> MEASUREMENT <br /> ~ .. <br />- ~; • <br />. .. REQUIREMENT <br />~ _i ~(~. :1 { _ I .i .. .. . <br /> SAMPLE ~. - ...: ...:.. ... .. ....,. .., f <br /> MEASUREMENT <br /> .PERMIT ..-.. .. ...: ... .. .:. .~.. .: ::.;. .. <br />~ <br />~ <br />. REQUIREMENT ~ - ~ ~i~ ~n,.~'+,I <br />1!75~ ~ )' a.I;. F. <br />ir <br /> SAMPLE 1 <br />• MEASUREMENT <br /> PERMIT .:,,. - ... ,:r~ <br />. - - REQUIREMENT , . ~ " „ ~. ~ ,. '•::i h'" <br />...: ~. ~ .. .:SAMPLE .. .. I a <br /> MEASUREMENT <br /> <br />/. ~ <br />PERMIT <br />~;,;_. ...,<:~ <br />r: r:, :. ::,: . <br />.. .. .. .. . <br />_ ! ~ ~ ~RE~UIREMENT ~ .... ~ ~X "~• <br />.: S :, s. ;.',. - 'SAMPLE .. ~ .. . <br />~ MEASU~IEEMENT <br />y~.;! <br />;;, <br />.. i ,_ <br />' fjERM1T . ... .... ,. .. - <br />' ~ ' '~ ' <br />L R ~IREMENT _ . e .. - <br />. <br /> '6AMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT. <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTI <br />AM FA FY UNDER PENALTY OF L <br />MIUM WITH THE INFO AW THAT I NAVE PERSONALLY E%AMINED MD <br />RMATON SUBMITTED HERON; MD BARED ON TELEPHONE DATE <br />~ L ,_. ^~, ~ <br />~ {.-: <br />f-E <br />~f'~ <br />~ MY INOUIM OF TNOBE INOIVIOUN.S IMMEDIATELY RESPONSIBLE FOR <br />OBTNNINO THE INFORMATION <br />I BEDEVE <br />E SUBMITTED INFORMATION IS ~+-' <br />. <br />i <br />_ <br />( <br />/~ <br />' <br />~ - - <br />J ,I , <br />TH <br />TRUE, ACCURATE MD COMRETE. I AM AWME THAT THERE ME <br />SIGNIFlCMT PENN <br />TIES FOP SUBMITTING FALSE INFORMATION <br />INCLUDING _ <br />. _ - <br />, <br />• '_' ~.` ~r'/..4if <br />~ ~ -' ~ <br />-. <br />~'~ '~ ~~ <br />'! ~ <br />•'[+' <br />~ i <br /> <br />L <br />,F- <br />.~ <br />.,, <br />~' ~ •L',o ~ R /' <br />/l t : <br />` ~~ ~ <br />f <br />[ <br />N ~;~ . <br />, <br />THE P0951BNTY OF RNE MD IMPNSONMENT <br />C <br />SEE to U <br />S <br />f 1001 MD 35 - .. ~ <br />` • •- / <br />) <br />. <br />, <br />. <br />. . <br />. <br />. <br />. <br />Bta <br />u <br />e <br />C SIGNATUREOF <br />PIi1NCIPAL <br />EXECUTNE <br />TYPED 011 PRINTED . <br />. <br />.E1 <br />./MWaN+ulw~dvrmnm+m+rlxAdlsro+wros/O,000 <br />+n0>m++Lm+n irrplwrwn P/blwrn smereY+rMSWV+.I j <br />. <br />OFFICER OR p'UTHOR2El7 GENT CODE HUMBER YEAR MO DAY <br />COMMENTS AND E)LYLANATION OF ANY VIOLA I IONS IRStsfence e// sttechmente here) <br />EPA Form 3920.1 (08.951 Previous editions mey be used, (REPLACES EPA FORM TAO WHICH MAY NOT BE USED.) - PAGE OF <br />