|
PERMITTEE NAMElAODRESS pwerlrFavMryNw/L«orlon I/n(Qbrenq
<br />NAME r.'rx.~ ~,(~~ r~it ra ~ E~i~: ~..in.~
<br />
<br />AooaESs t,/~tEL~Lt)~r#~; `.sfS'#'~. aJ 1~,#~i'~t (V-#-(';'E ('# ~ "~r_.t~
<br />
<br />
<br />FACILITY. 7it#L~#?'~j';i'; C;i:ef~t Rc ~i...~= ~=#~i•'~. t1II~SE~
<br />LOCATION ~`3~Iv#'r`".-''1~,`'.i~.T C?~ i~%. ~+F~E•
<br />r±i T i 2'4: a,i.~-,i`'E1".ti ~ ~~i~l~"_~: ~~~ia 'a%°. #'.
<br />NATIONAL POLLUTANT OISCHAROE ELIMINATION 3r3TEM //NPDESI
<br />DISCHARGE MONITORING REPORT IDMR/
<br />PERMIT NUMBER ascNa+waE NuMeER
<br />MONITORING PERIOD
<br />YEAR MO., DA YEAR MO.. Dll1G
<br />FROM _ ~. " ` TO ~ r._ _ ,
<br />Form Approved.
<br />OMB No. 2040-0004
<br />it`E ~. ttEl.aE^.i e
<br />t. ~li~.~2 t~iH
<br />1t..7:Yr't~ i'~t..~tattt' s' ~TL~i t'~. i•'ri cz~j'.~i'a #. „~F,,,{jti i~ ~
<br />:i• ~• ~ j~it~ Lt ~.~..%{~i`i~:'~'+:i':,.. i ,/~ i ~~ :r •z
<br />NOTE: R~~d irntructiaa 6~ior~ complytiny this form.
<br />PARAMETER QUANTITY OR LOADING 4UALITY OR CONCENTRATION NO,
<br />
<br />EX FnEOUENCV
<br />OF SAMPLE
<br />
<br />TYPE
<br /> ANALrsls
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br /> SAMPLE •.~•• ., .. , -~ ~• . x~• :c : -~• ~~ ., ~ ;
<br /> MEASUREMENT
<br /><'; ~1~~•~'~ Z ~+ t7 PERMIT ~' ~ ,; x •fb'.ti 3s'• r3. ~
<br />•s,
<br />~ ;
<br />i~v ~ l
<br />it ='~ir ~,'~iza~i.. flR.C7 a~ tlf-~L..t.{r. :pEQUIREMENY :~::s •~••~ f'7 I I'd T >~ItJC'i i~t/'jX T. tit~t'i ~L.I C9[3t".1 i i-i
<br />._ s ,_ _.+, _.t ~ ;-~~ - SAMPLE N•-., :~ :. n ., ... „ „ ., ~ w•i; z•x~T•~: a. °r e
<br />rt.Jc7f' i;` ~; ~aF:'~' MEASUREMENT
<br />,mot v :a ~ ~l ,~ ` 1 f~
<br />:PERMIT # •##• ~• f i't !',
<br />_
<br />~E=~'E«.IJE~'I~i' o~i~'~,~i:~ t?~rLi..{E pEQl11REMENT
<br />:: :~~E•:t•# ~U~A A'v~~ L?t~~i.Y t'iX ##t:%f#.. 1`i-~('~TH
<br />..vul_. _ ~. ..a.~- i . -.i•. SAMPLE ;r:~ x :, x ~ , ., ~. a :~ .. ., n :a••x:~•:x r:?!
<br /> MEASUREMENT
<br />4I~ .C~ j(' .i".t ~ ~~. t S (.? :P!<RWIIT' ., Y{..x..~r. 'z ~ n C l 7~ t} i ~, C , i C f i ~'
<br />
<br />~vfRL~i. "+~ :d`r•vi_~d
<br />•1=i:`i.,t.fi~i"dT ~
<br />QUIREMENT,
<br />-tE
<br />:i~F#
<br />~~' r"±`,~t~
<br />;;L'~r}
<br />i.}Fi-~ Y
<br />{-~ '3 f"i~ ..,
<br />E'ij. `i__ fdl
<br />S'1v i-i
<br />.. . , }... i.... SAMPLE se .... z-s~ •~r x•n• :...;,~x• •~-xzrr, -R• n t. ~._ _: 1
<br />( f~::. ~L• ` MEASUREMENT
<br />S~;i.'~~f 7 , f5 ~, .:;PERMIT-...: `~" , ~ -~~x•sb v'~.~# ~~ t~ ~r: r ::r.~ ~
<br />': ' `' c~~ :,/ i
<br />~'.~ i' L..(_4t~.I`< t f~~~~1 1. {:a ~i. { REhUIREMENT
<br />:k•'tt."sY2• ~'
<br />.~QE~A ~i "l.~ f ~
<br />~~i I _.~Y 'r k 1
<br />t_ i-', •i.... v
<br />f ~~I E
<br />~ y>r r-~ttl~.' txt{t.a ~,°- SAMPLE -.~~I.~t•.:r i-:: •~ ;r~•~•-it••~• •if-sl..~..~..~•~r t ~.. ;•
<br /> MEASUREMENT
<br />u°~~~"tt~? <. ~ c~ PERMIT >: ~,t••?~•at. ~ .~~. a .i ~! . ;~ - r
<br />~~~F`i_ca~#k.ET Cz~ri"?'>`:; 'J~i_(,1 F~~t]UIREMENT> :,i..~.,~••~. I fuS i f-iA x i°:t'~~ f L. ~`=c~C•a i
<br />r ]. I '1 Z _.T SAMPLE LI,:F P a .,. ~ .;, _, .. _ <r r-.- a ... ,_ ,._ .
<br />.Er•~t~# ~
<br />s '('iti«~:F4Tt'it=E'•~T i~i
<br />TME~i MEASUREMENT
<br />..
<br />.
<br />~J'~ ~ Ta' ~ .L ~ t
<br />'PERMIT I'
<br />K
<br />~ st •~ . st ~ ~ xr -ir ~ {{ •:#• :i• is C , ~ f ,. ~
<br />I~~"•'ErIJ~E`a'~° "1*C~~~ ~i~•si~t~{ .AEnuIREM~N7' ;3Gi7A AVC# D{vIi*Y hVx. r°1~i: ~-~•~••~• i~i7NTP-i
<br />~~.~ .. _ a: .. .. SAMPLE f ;- - ~ _ra. - ,. i .u ~,
<br />Tom` ;~ ~;SL~'~...~1I £} MEASUREMENT
<br /> f!ERMIT
<br />~F'~'LL3~.i.I-i~ t;F,i?~.~:~a ~'~L.(.J :REauiREMENT ~~~'~~ (3i?7i? AVt~ ~~';Ii,_1' i~+K t'ityr'L
<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER ' "^'tr ° er pena ty o Iow tlut Ih
<br />direetlon or aup
<br />re
<br />onM under m lr e«vmem one el utoehrnenb were
<br />ersMon In oeeordortre wllh ~ >>slem derl`ned TELEPHON E DATE
<br />"'7' /~",,
<br />(I ~~ J / `~ ,~ "~'~ p
<br />p
<br />y
<br />to enure thot quoNfled perwnrrel P~H7 6olher and erdunte the InformoUon
<br />nrbmitled. Seed on m~ Irpulry of the pervert or pence who mona`e the ryslem ~„s.~ f i
<br />'
<br />•
<br />^
<br />'
<br />v , ( ~~ 6~~ ~
<br />~ ~ ~a?•1 /'i°! /
<br />t
<br />' / or thox pence dlrecll~ respoelDk for ptherln` Ibe Information, the Inform~llon . l a
<br />a
<br />~
<br />~
<br />~f
<br />`~ y // ~~.,. ] rCJ~
<br />` ( ~, lll~~~ J
<br />v svbmllted b, to the best of m~ knowkdEe and betlef, Irve, onvnte, and mmplele.
<br />v EIONATURE OF PRINCIPA EXECUTIVE / - ,~/i G
<br />/ ~ L:~ ~. j ~j / Cl Z..
<br />/ 1 ram aware that there ore fl~nlllnnt penaltles (or wbmlitln~ hbe informeflon, OF
<br />I
<br />OR
<br />UTHORI C NUMBER YEAR MO DAY
<br />TYPED ~ PRINTEp Indudin` the pomlbllllr of Ilne and Irttprtaonment for knowln` rldoeorn. CER
<br />F
<br />A
<br />ZED AGENT ODE
<br />COMMENTS ANO EXPLANATION OF ANY VIOLATIONS /RN~r~nc~ sl/ itt~chmlrnts h~i~l
<br />,~~s iE• ~-~~~~-.-_ ~i~;~;:r~ E_~.E~°~x'I-~ ~z~.;_ ~~::a~z=,~~ n; ~=a¢,E,~ c~:Ti~~:¢',~_~i_..r~:. ~~:,~_ ~:r~~ ~_t'~~~ f~~~#__~,~,~~ .-.~;~~ .,- :{.cY ., ~ .~ ~ ~, ~-'~ r.i.~ ~.',~~..#T;
<br />"€"': [_1w:AL~Lk `L7i~.:'c'7t~ i:..Ii'[#'."i~ t'#~~:5~'
<br />~:'1. i_#I= ?F;rr•t1:t1k:;S~ F "r ~~ ~.~::•"{F', ti'=•i•-l~ E=~~t'aT ~ SI=B:: 'i:. F4. /., ;`'~ ~--:! <=.i',iL~ I. ~,. r~, ~'. ~ i+"CiFt #~:GC'ii51T~.
<br />.
<br />r" ~ 4w _ •j ~; .. t ^5'... L` C' =" .. - .... .. ~ 7 - ~" ! ,- 7 ° C•' ~5-' s ^5 :! i ' ' rr T: C.,.. .l ._. ~ ; . tai n •-'1:~ '{' ~. t" ~ ~ ..
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions maybe used. ; i; }q. c~'~ ~ ~^ ~,~::~$~a:4-Pa{I:~rm. PAGE ~OF
<br />
|