|
PERMITTEE NAME/I' CRESS pwdJ. fsWryNnW/uwo. dOrdbrwp
<br />NAME
<br />ADDRESS :.~: .),,.,, 7 ' ... ..
<br />'L:. r..
<br />_ij .,i~ai
<br />FACILITY
<br />LOCATION ,i 1 -
<br />~. i.: 1'IK ~. I ,e. I'I ln.,t .~
<br />NATIONAL POLLUTM' 'CNMOE ELMINAT,OM 9Y9TEM (NPDESI Form A~ ~~ed.
<br />DISCHARF )NITORINO REPORT DMRI - ,OMB Nr 40-0004
<br />-. r , ,, ;, ~ / ~ 'Approval erpirae 06=31'-9&
<br />PERMIT NUMBER OI9CHMGE NUMBER ~, r- T 1 . " - - "
<br />MONITORING PERIOD "='~(-`
<br />YEAR MO DAY YEAR MO DAY
<br />FROM / -1 C 7 .. I TQ 9 7 C 9 : C ; :: r ; , . ; ., :... i r, I
<br />!161/1 (11-I31 114751 (16-171 /1B-291 (3P3!! -' NOTE: Rasd Initructlone bafori ~eompletiny th4 form.
<br />PARAMETER !3 and Onlrl QUANTITY OR LOADING !4 and Onlr/ QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE
<br /> 06531 !5487 (38-I51 (4653 /5457/ OF
<br />131-77I E% MALrsls TYPE
<br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MA%IMUM UNITS /s7.n•
<br />Tl
<br /> , (54551 (55-701
<br /> SAMPLE ::; ,; :;: :'. .. . { t/~: ;: ::: ( : ? f
<br /> MEASUREMENT
<br />:. ., . ~ .. PERMIT ~ , .:e}a.r:. , , .. ~ ~
<br />'
<br />!~'
<br />~~ /i. p/ {. >: tl .,
<br />. /:
<br />!
<br />'{
<br />.
<br />:.
<br />r I :; t...: :. , I ~. I = 1.'; i REQUIREMENT ~ .. .
<br />o
<br />. ~P ~ I
<br />K , Y ~ ; . .
<br />:,_.1., ,, ,'.i,i. SAMPLE ', ,:: :: :~:.. ;: a::p ::. q.q :{:r ~ .:,I
<br /> MEASUREMENT '
<br />I
<br />.., ., : ~. PERMIT Y= ...: ,~ . rp r,:. . ~j::= ;^;7:i f.' ; ~
<br />~ ~ 7 f; -
<br />i ; I.. . ~, •
<br />'f. REQUIREMENT .
<br />7 .e y ~
<br />r
<br />, " ' ' ' '
<br />:.: .. ..:~. I '~ 1. °:.~, -~ t. _. SAMPLE .. ... , .
<br /> MEASUREMENT
<br />,l, .o .,. r. {: - ~. ~PERMIT~ .' ,?W,'::7 ;: i.:
<br />~ ::{:. Yc.'.. :i,:' { ,Y: i+'-1 ..~ l
<br />~Y Qf':}{: iJ. r .
<br />~
<br />< ~
<br />~ REQUIREMENT ~~~
<br />: : .. ~ ,
<br />~~
<br />: ...~ .,f /
<br />~ ,..
<br />.
<br />; '.1{~)
<br />irL..:.u
<br />i.i!.;/; . ;:;j;,,:~ .
<br />. ~rt,: ,
<br />„
<br />' .i: .l ..,. SAMPLE .;<~: ;::7 ;: u
<br />{~ :i r ~. ) {~
<br />>: :::,a :; .i
<br />r ; ~
<br />' MEASUREMENT
<br />. _ ., .. _ ~. I ., .. .. .. , .
<br />t.: it
<br />~4 :.~.. L If .. ~~-PERMIT:'~.~ ,F i; yr:{::?;: .~
<br />~
<br />... ,.
<br />.. .:; o;::r ,::
<br />~..
<br />?.. {: ~r?r A~,?>:' >:~3 :: L~~:n"•~. 1:('.~ ~ i '
<br />'
<br />~
<br />~
<br />~ r REQUIREMENT : ~ ~ ..: ~:
<br />~ ~ . _
<br />.
<br />: .
<br />,
<br />,
<br />.- , l..-.: :
<br />~ r
<br />. _ ., , I ~ .:: L , .
<br />. ......
<br />.. .. :, :, L ::
<br />(~ .^ ; : ;
<br /> MEASUREMENT
<br />(:., t .;
<br />.. , r' "PERMIT :~v:' - ~i;• 1:; :):: :.J (': .~5 ''
<br />f;
<br />`)(r f
<br />/,, .REQUIREMENT ~ ~ ~~ ~ ~ ~ "~
<br />..,, .. ., ..- !'n SAMPLE ( l.i j) :t/': ;;{ p>; r,.' .. .. ,
<br />:'
<br />~ i
<br />'
<br />'
<br />~ MEASUREMENT
<br />E
<br />.., ....: 1
<br />.. ,
<br />- ;, ;
<br />~ :, .:
<br />. .,: ,, l;
<br />~ ~ PERMIT. Ir'~1`1(i i'{r i.' :: I'i77;i ~{:~:' :;. t: {. ,'t,;{+' ~ i.•
<br />:
<br />r i~i 1. :. :' :~I.-. ~; ;i~.L_I! REQUIREMENT i:1 .)~n ~~~~n.: i~'i '~'! (Ili
<br />~~
<br />,:.. J-,, il'.j. ..L SAMPLE .. ... ..K ,:V {~~:-i {. rr r: (
<br />::;~
<br />~; ~, L.! I ;, MEASUREMENT
<br />'.. .: ,^ i t, .~. PERM.IT~., ~~.::;:r~.r,..:~,;~~..: ...~;:,;::.:'s~::~ .. r: ~;,,jr:Y ~:yOe;Y,:y' J
<br />
<br />. ,: ~ ~ ,; ,~~~ r : ; ~' { ;. 1. !.
<br />REQUIREMENT.
<br />~:: ~ .~:
<br />~ ~
<br />;: ~:;:::~
<br />~ ~
<br />. ~ ... .. _
<br />P7,*Tv
<br />~
<br />.. ..
<br />1
<br />
<br />.
<br />.. .
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I OERTI
<br />AM FA FY UNDF11 PENALTY OF l
<br />MNM WITH THE INFOI AW THAT I HAVE PEg50NALLY E%AMINED MD
<br />IMATION SUBMITTED NEREIN
<br />MD BA9E0 ON ~
<br />' TELEPHONE DATE
<br /> ;
<br />MY IMOUIRr OF THOSF INDINOUALS IMMEDIATELY RESPONSIBLE FOR ~
<br />i
<br />~ ~
<br />~
<br /> OBTNNINO THE INFOMAATON, 16EUEVE THE SUBMITTED INFORMATION 19 ~ '
<br />
<br />-~~ ~~_ ~ ~ TRUE. ACCUMTE AND COMPLETE. I AM AWME THAT THERE ME
<br />SIONIFICMT PENALTIES FOR BUBMITTINO FALSE INFOMIATIOM
<br />INLLUDINO _ .' ~ : + < (,: (. cj (:~ "'-'-~
<br />~ ' ' -
<br />•-
<br />~
<br />~
<br />
<br />i'
<br />' ,
<br />THE POSSBIUTY OF RNE MD IMPWSONMENT
<br />SEE I! U
<br />S
<br />C
<br />E 100
<br />MO 77 ,
<br />~ :
<br />' i;
<br />I ~ /
<br />I j ,
<br />j; t I
<br />. ~ ~ i
<br />_ ~ ), .
<br />.
<br />.
<br />.
<br />1
<br />9
<br />c BIONATURE OF PIIINCIPAL EXECUTNE .
<br />
<br />TYPED 011 PRINTED u.
<br />.
<br />. 1 1716. lhrrNb uvr BMr mrvro• „nr bFA-d• A,., y ro ! lo,aoD
<br />AMSnNUYnn, iASim,w,rWMNrn smmNa uderwal
<br />~ OFFlCER OR AE7EHORRED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />a.~mmcn, ~ nn~ cnrcnnn uvn yr nn. nv~n I rvnJ ,nerermce en auacnnoms nws/
<br />.I ....-, ,...~ .... ., ~ 1-T:'r, ~,1 Li,.., ;••.1.'i -:'ti, 14-:I !. J8 F~1F EV ct+' 15 Cl~ .' ,,. .. :.. l .... : i
<br />~,, ..~ !.. :...".1 ... ..,~ ]. _ C i,~i'i.7 c. :1+ `iai... .:'I~- '.i °_UPc MEN?S-"Cr. i~ T../r'. .. •~ .. !'
<br />EPA Form 3320.1 108-961'~Previous"sditioni may b~e uded.- ' " (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br />0(`U3l/9'1'1]1 !-'!'i:
<br />
|