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FEAMITTEE NAME/ADORE 55 (In: InJe NATrUNAL POLLUTI.NT DISCHARGE ELIMINATION SYSTEM (IJ{'U{J l <br />l erilily' A'+mr.d.nrarinn iI JifferenU DISCHARGE MONITORING REPORT r DAIRI <br />NAME_S,I:-~_~d-~-1+~ti-u--~~=~-I~+j_i_-- !~-Ihl rl7-!'/I {~r .~l{ <br />AODRE551 L,LiLLL r..~--Y~L~'----------- '~nls - ~I) .~'~I (g1113R +!1) Fafr~~Proved. <br />i- / PERMIT NUMBER olzcRgwco rvaRecB 1 _ ~ rl „~ ~ R r OM13 ND. 2040-0004 <br />_L~ ~ :1'1;---------1..-__-.:111-_ <br />--- ----- MONITORING PERIOD ~-!if r7 +1 T._ W°rRSjFYwrQTp, r. 1."~Yi '009 <br />FACILITY <br />------ YEAR MO DAY YEAR MO DAY <br />q 7{~ <br />~ <br />~ <br />1. <br />LOCATION 6(Ju~W4=f{L ~KlrtO"~------- FROM 'II !i ^.1 TO ~'i 1~~] ~'1 ~v M'~ DT iii .4 R'r ~; __ #$$ <br />I <br />I <br />~~ <br />t I' . i : r i ~ S ' D F V " r 'o 'u r ~! '.u r'+ ?f / r>A ~)1 r!s-'YI (aa :+I I NOTE: Read instructions belDre completing this form. <br /> ~~ r.l ('aN Ouly) O ANTITY OR LOADING M ('.I rA Only') QUALITY OR CONCENTRATION <br /> <br />PARAMETER <br />~ <br />' <br />(JA :f.i/ ri.l~nll <br />(IS-.Lfl (~d-SJ1 rfa-All <br />NO. FflE WENCY <br />~ <br />SAMPLE ~. <br />t <br />I7' JI / <br />~ <br />~ ~ EX Awv515 TYPE <br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS <br /> fd: dJ1 <br />rdldHl <br />fdY4Ul <br />' P) L L ~ I P ° <br />~ SAMPLE <br />MEASUREMENT s ~ ~ ~ • ,. • . • . . <br />7 1 {~ O r J . , v <br />~ v~f ~ ( Z [. l <br />~ <br />'l ~O <br />/U <br />I)~a ~.T i ') ~ PERMIT $iY$'zt $. ..$i`i•+F$ r~ RIi-P1[~T' $=k'~$~~~1 $r$${Fi { ~V~ <br />- R. <br />4RLY <br />Dl1P 5 <br />)y <br />;; '~"j~:V ~ R~+1 REQUIREMENT <br />, tl o <br />N t ~ <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 /> MEASUREMEiT <br /> PERMIT <br /> REQUIREMENT ~ ' ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cERnF-r uuDER PENPLTY of LAW rHAr r HgvE PERSONALLY Es AMweD TELEPHONE D A T E <br /> <br />eM.ltins ~0~ PND AM FAMILIAR WITH THE rNFORMPTrON SUBMITTED HEREIN. qN0 BPSEO <br />ON MY INQUIRY OF TFR]SE INOIV IDIIALS IMMEGATELV RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMgTIIXJ IS <br />./ r <br />1 <br />' <br />I <br />n TRUE. ACUUFATE ANO COMPLETE 1 AM AWARE THAT THERE qRE <br />G <br />' <br />~' <br />Lt`{ <br />^ <br />1 C <br />} <br />~V 4 ,S V SI <br />NIFICANT PEIJALTIES FCH SUBMITTING FPLSE INFORMGTION INCLUDING <br />THE POSSIBILILT OF FINE PNO IMPRISONMENT SEE IB USC { rWr AND <br />i <br />Po <br />SIGNATURE OF PRI CIPAL E%ECUTIVE / 2~rI <br />] <br />f/ i ~:J //7 t <br /> <br />TY PEO R PRINTED s3 USC <br />I]r9 r <br />neluD unJO Ihrsc statutes m.rl mduJC ones uJ ro <br />flU11IX1 +nd nr m+omarn unprnnnnmm .0 horxcen n mnntln •nJ 5 le+rs 1 <br />OFFICER OR A HORIZED AGENT <br />AREA <br />NUMBER <br />TEAR <br />MO <br />DAY <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS 1 Rekrcnee ell ar(+a'hnlenls here/ / <br />S°:t: PaRY~'.1w11 FDI{ PF;SP PRDC. RPi R~:DLTS 7P Li:PH~~Y Dt:I1iVAPNti .45 °:''PP?:'T"~ .R04T!15 RP.P3l1D~RTIAT~S AS <br />Ri~i(TCIT HI)1' LJH?SPb;FPL AP a'.1T"' "*~TTSPTT'ALLY ~+!ITF DI!~P il'PV !'f:5'!':Cl.'ITi1(1L VAS Q9'i.°,R7'?D STN, '{R51 <br />,gin-o ~ a., r.,- ., ~- .. .. ..... .. .. ._ -. <br />