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PERMITTEE NAME/r " -9E55 (I~4 FswryNwWlacaNa~ dD10 .1) <br />NAME ~ . , _ ~ ~ ., .. - .... % ., ~' -.. ~ <br />ADDRESS .. i _. , .. ?' i .1 :. <br />.. .. ..... (.t) :: l:. li L <br />FACILITY <br />LOCATION <br />~ ~ r <br />NATIONAL POLLUTAN• "'CMMOE EUMINATON SYSTEM (NPDESI Form Ap^~~~vad. <br />DISCHARF 1NITORING REPORT lOMR1 ' <br />r1-l5, n-!s ~ . C • `'' - 1 OMB, N. w-0004. <br />' • r, i~ f'~ ' ; r• c , , .l ~ ~ ~"Approval expires OS-31-98 <br />PERMIT NUMBER DISCMMOE NUMBER (~ ~~ ~ ~ ' ' <br />I' r i . <br />MONITORING PERIOD - •' •~ -~ <br />YEAR MO DAY YEAR MO DAV <br />FROM :~ C l ~~: ~.~ 1 TD i 7 1 ."' j ..'. :; 1: ,, i .. r":: I T.% I ':_ , <br />!16171 111-Z31 !14151 /16-171 11B-191 13P3// ~ NOTE: Raed InitrUCEloru before -edmpleElRp Ehis form. <br />PARAMETER l36rd On/Y1 QUANTITY OR LOADING 10 Grd On/Y1 QUANTITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> 106531 /51-57) /38-051 14653 /5467/ OF <br />137-371 EX AN,ursls TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS lFDS] <br /> ! r50-5B1 r5s7a <br />:, ..'~ ., ., ~. ~.: SAMPLE :: ~:: ::: ::: :.~:,. ( ..n~i ::. :);: ~: n:; ,; :; r~:i i. ,:: ... .,. <br />~ ~ ' <br /> MEASUREMENT <br />. L. <br />~, ~.. ~.. ,: :: i ~ ~ PERMIT <br /> REQUIREMENT <br />I . <br /> ,~:-:, _ <br />/ <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 1 DERTIFr uNDFA PENALTY of <br />AM FAMILIAR WITH THE INFO uw THAT 1 HAVE PERSONALLY ExAMINED AND <br />RMATION SUBMITTED HEPEIN; AMD BASED ON ~ TELEPHONE DATE <br /> MY INQUIRY OF THOSE INDINDUAL9 IMMEDIATELY RESPONSIBLE FOP ~ / <br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INfORMAT10M 19 <br />! <br />~ <br />' <br />-' TRUE, ACCURATE AND COM0.ETE. I AM AWARE THAT THFRE ARE <br />SIGNIFICANT PFNALPE9 FOR SUBMITTING FALSE INFORMATION <br />INCLUDING ~ ' 7 <br />"- ; ( ~ ~?.'r' <br />"- <br />~ ~ ~' <br /> <br />' ~ <br />~ , <br />I ' _ <br />' <br />' <br />' <br />, <br />- ~ <br />' ' ~ ~ <br />~ ~' THE P0651BIUTY OF RNE AND IMPNSONMFNT. SEE 1B U.S.C. 1 1001 AND ]] <br />610NATURE OF PRINCIPAL EXECUTNE . _ <br />i <br />; <br />I <br />l <br />~ <br />~ - <br /> U.9.C. 1 1]n. lFMMe4a law 1Mw mroroa nlaY IncbFa Aaq y ro ! 10,000 AREA <br />TYPED OR PRINTED xNwmublvn hlnladMlMrW hnawnemongaxM 6Ywaa/ OFFICER OR AUfMORIZED AGENT CODE NUMBER YEAR MO DAV <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRe7erencs s// ettschments here/ <br />...,...I.,:~i..: '!.. ~ Llr'.1: r.Pbi.:i~... .,r.!.Y ., <- iu-Y.Ia .:h-;!i: i~k ~fiF FY:t1 I:i C';.:1fi~.:,. "1' •'i.-[•. F!i`;7:. , <br />_:F 'i ... -... ..?i!i') ,.; i. i. oJl ., nr:'L j:.i~ :L :( !'Ci:, `; i.' .,.. F`UhFCEb'r_--~1" i.F..l?~ I'~., li .. ..-~!~r ~~ <br />EPA Foim 3320=1~ 10&-96) Previous editions"rosy b'e used. - ~ IREPLACE6 FPA FORM T~0 WHICH MAY NOT BE USED.I PAGE Of <br />