|
PERMII7EE NAMEIADDRE85 (/1Nlndr NATIONAL POLLUTANT DISONARGE ELIMINATION BYSTEM INPDESI FDRT AppfOVBd.
<br />ErdIIV Namr/Lowllon UdUJrrenp DISCHARGE MONITORING REPORT /OMRI
<br />NAYC M-G ('f1A I. C'rrHD 14Y /1-161 In.IQI n _ n r rr A r OMB No.2W0-0001
<br />ADDRESS N F~ t D P. N G t7l.C H !'I 4 F Clr !: 1 S Q ~ 1 q !! r T n Approval aagrea ea0-BI
<br />~----___-- r i ~N04/UFFTCF. 0.1.,.0. PO,tD
<br />~;' PEpM1T NUMBER '' =' ° " DISCHARGE NUMBER
<br />---iL31S:'tA'C~~L:~LIUL13--_--=~- - ° _ L: _
<br />^
<br />ypp~~r~ptr~~ ,(~/~ ' ,1 ~
<br />'
<br />MONITORING PERIOD ~ ~
<br />_
<br />~* '~'
<br />I
<br />_
<br />FACILITY _ _ _~ . ' _ _ ^ _- ~ ~ ~ - _ _ _~ - ~ YEAR MO DAY YEAR MO DAY ? ~ - ~
<br />~ • - ~~ - ~ n
<br />LOCATION ~ 'L _ _ _ '~~
<br />'" ,FROhI •t0 Hr•rnD i~rlnp' `~~) ~ •'.R7[IT? .
<br />~~~
<br />_
<br />?
<br />T C' ^
<br />,1 i T 1: S F'.. K . ' Gl S'r II Pit ° ~ [ U ° H T ~ !16111 lu-1T1 111•SSl 176-111 Ra-191 /363/1 NOTE: Read Inslrupllcns before oolnplellrig this lorm.
<br />
<br />R
<br />~ ~ (3 Cab Only) ij QUANTITY OR OA~INO .~, :~
<br />' pF0 Onlrl:: QUALITY OR CONCENTRATION ! I; 1. :' ~
<br />~ FpEOUENCY
<br />S
<br />E
<br />PARAMETE
<br />~ - i 11673/ - ~ (71-0l1 r~ -• 138171 /167!1 /JI-01/ ' u
<br />rte. : :E%' bF TYPE
<br />131-1j)- .~
<br />~• .- ~ ',: „ AVERAGE^''
<br />„ G o-MA%IMUM^ ~ UNITS' ~~
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM ~ ~
<br />~ UNI'f5." ~ ~'
<br />~-~ :ANALrs15
<br />~ ~ IN-6Bl I
<br />1
<br />'09-701
<br />11 O ip v SAMPLE = ~~=#Y.-' 00 ^ ~ -~fi0~ rv ^ .Z ~ ._]
<br />^ a fi~lklY ~C 1 Q ... n ~ ~ 3 ~_,
<br />..
<br />~ C f~EASUREMENT~ a O „ N :1 C r.T
<br />- , 3 - I
<br />_ a O p. M1
<br />i
<br />~ ~T _ ~, r .' ;
<br />)71100 1 d' t-U tt~ ~ A ~ u °i ~:'
<br />~ g
<br />_
<br />.fF1.UP.NT GRA S YAL Ip 4 ~^° ~ .` g R ~ `
<br />.nLIDS, SE'~'a°.APLF. a ~~ SAMPI~{ ~ ~fis`'ka"oa=
<br />' ~ e a^
<br />'
<br />~ ° r~ m ~ ~ o Kaa v aIIGgLOria
<br />[* ~ ,~ ~ - .; ~N
<br />' ~
<br />~r ~
<br />S LIFASURE ENT b
<br />1D ~ q
<br />7 . O. h .+ ~ t > >
<br />~N _ ti ~ Q
<br />y - - __ -t ,~ ,
<br /> a ~ G ~ H
<br />T I ^ .
<br />1 N C S III ^#Y+~~ K -.
<br />rIL IIRD G.R~I1sE ^O Uple
<br />NTC
<br />~ p~ ~fifib~ ° ~I~tgO~ Oo
<br />~ ~ ao . - s _~d~OIQt$go -#IGYSO
<br />",- . ~. ~ a @' ' m ~' I
<br />'RF,OM F.XT~t~91lVrpMH'~I sEA
<br />E
<br />P sue:=. .~^ ~ ~. ~ _ - ___ _ >,
<br />,
<br />
<br />'FP 1 I .~ r ~ p P ~' : 'q ~ °'
<br />'Lr)v, LN ¢r~thui o4` o 5A IOIPL~ p4fiOtlrt~ o : r ,: .~ ;., -
<br />v
<br />• ,_~~;~~: _ .. , _
<br />~ ~
<br />~
<br />H R I) T R E1lA~' ,~ fIT 'Q ~ ~' MEASUPEMENTr
<br />- i .r Q ~ 1
<br />C; ~ n fi
<br />.7(1.0 1 ~ ~ ~ ~ f? PEII
<br />1
<br />~ ~' ~ ,~I> t' ~ y~~~~
<br />.
<br />"~
<br />S? r
<br />>yl~ 0:~ ~
<br />y
<br />','+:fj, ~ TI ~~ ~ Ter:
<br /> ~ii
<br />E F:
<br />r: ., .
<br />~ -
<br />~ ..,... .-
<br />«.. . _.
<br />171,1 DSa TcQ ti~~ rwr~~
<br />'~~ r sAMPLE ~, °~ Qfi C4Crb
<br />^L~ ! 7~ n41~
<br />~ n % ~~.~'r np~
<br />~ ~
<br />~' + f}p ~,J 1,
<br />0 I
<br />, ~1
<br />~ ; ~ u
<br />LT ~" ~ .
<br />rr I
<br />.
<br />~ v Ir.~ flEA9NREMENT_ ~ 4 V .a C * ~ .,n
<br />~: u ~ ;
<br />1'1 ? 9 S 1 ti'. Q' tl ~: .P
<br />MM.~}
<br />.
<br />NdFi q
<br />~ I ~ ? 5 t'~ r.-
<br />I w. >, , . ,~ ~ ~ _ ,t R A
<br /> E . I , ,
<br />~" ` ,
<br />..
<br />
<br />'IL 0.}tD CFgaIS'E •`
<br />I. SAMPLE .m
<br />?I¢.fin~t~YF:
<br />N Fi, a
<br />c
<br />o ;i
<br />I
<br />~rtrt+Cn.`•,;"
<br />~ 'g+Axr.•;Y
<br />!:fivt~,.^fi~
<br />E: ~ r:
<br />,
<br />U
<br />A,
<br />! F S tl A L ~ sy ! V ~ MEASUREMENT-: .~ !i
<br />
<br />' i ~ N p N +. .- .. I I+ _. ~:]
<br />`, r
<br />h
<br />L
<br />InOGS 1 `''0` -A ~
<br />~
<br />,
<br />~ `~
<br />Y, PpnM~ ~
<br />B
<br />D NTa ,
<br />QQ
<br />,
<br />`~
<br />r ~3
<br />~'~'=1;~~
<br />r. ~~'0.',~,
<br />r40~F'~A.-,
<br />i,'.;O+i94
<br />O _
<br />t~i:o _
<br />.4
<br />l~
<br />I
<br />VA1.,
<br />1
<br />4
<br />:FF 11 H* (' n
<br />5 EM . 9''
<br />r C . y : .Y.':. '~.
<br />• _~~ r :s t.-
<br />Y
<br />l .y
<br />x .~ O c. /] ~.
<br />~ G .. SAMPLE a
<br />~ `~.Q ~. -
<br />u C ~ i ~ <
<br />~ j •~ ` -'~ ~ ~i~ V
<br />,- ~ ~ ".] C i r J ^
<br />~
<br />.J
<br />-1
<br />i6 to
<br />., U
<br />. .. QEASUREMENT _
<br />~
<br />~
<br />.. . .~ '
<br /> :
<br /> .
<br />p.
<br />+ _ ,,y, _ ~ _ _ _
<br />•
<br />F
<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER-: ~' CERTI
<br />AND AM FY UNDER PENALTY bF
<br />LAW THAT I HAVE P
<br />FAMILIAR WITH THfi INFORMATION SUBMITT ERSDNALLY E
<br />ED HEREIN
<br />A XAMINED - ~. 'i ',° ~ "
<br />~'
<br />ND BASED
<br />~ ! / ',TELEPNONE - DATE
<br />,
<br />'
<br />~~~ 1'
<br />~ ;
<br />I
<br />.l ~
<br />ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR / F
<br />~~ ~ - ~
<br />- :~ ;
<br />_
<br />~- ..
<br />RICFIAIiU (i~ ATKINSUN
<br />OBTAINING THE INFORMATION. 1 BELIEVE THE SUBMITTED INFORMATION ,~
<br />.
<br />,r ~' ~
<br />,
<br />1r ',IS TRUE, ACCURATE AHD COMPLETE. I AM AWARE THAT THERE ARE SIO~ ~ / .~r_-
<br />- =~
<br />VI' 1, D/EBVj.ItONP1ENTAL.^/I,F$AIB
<br />-~ ..
<br />-' NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1S U.S.C; 111001 AND
<br />.SIGNATURE OF PRINCIPAL EXECUTIVE
<br />1918
<br />3J U
<br />S
<br />C
<br />P
<br />l
<br />d
<br />A
<br />w
<br />7
<br />d
<br />I
<br />'
<br />' 3113 824=4L52
<br />- ~ ~92 III l1 t
<br />TYPED OR PRINTED .
<br />.
<br />. I
<br />em
<br />ua vn
<br />rr r
<br />S.ee imrb0
<br />ay Au
<br />.
<br />/
<br />nrt
<br />. 1
<br />e
<br />up4o 710.000
<br />andwma:lmum lmp4anmenl o/hlwenamomNand lytanl _ OFFICER OR AUTHORIZED AGENT NUYBER YEAp MO DAY
<br />•COMMENT,AND EXPLANATION OF ANY VIOLATION S/Rekrvnre Ollairachmrn(a hertl I
<br />u
<br />flr/, f,,G~Sr?7i 9CF F'lO T'17TF r/~ Dq!l P. 3 nF' DFRHTT. ~R'r Fl?Lv DFP°T'T'•l p^, '"'-r1~T~'tU7 .l Y^ t'rYr; ~T1 Qrr1~
<br />EPA Form 3924_.- eV. aBB1 P/IVIOYS ed/IIOnB mey b1 l/Sed. (REFUGES EPA FORT 1 HIGH MAY NOT BE USED.I .SE OF
<br />
|