|
PERMTTTEE NAMElAODRESS pneirJrP.erbryN.w/Loeuren t/Otpbenq
<br />NAME t~?;X3t`-}(>~ ~}!'}'~~'}'`*}~r L}...v
<br />ADDRESS,=.•+F'ct~~~}RrS ';~I~. 4'.f ~'S_}'~. ~`~?~ F''}r{'~I~.C
<br />ham. ©. L~:3X ~•'~"~.
<br />FACILITY t,.,t-'r~14~}~t`~t~t (.',~}-'~ ~•: ~}....}+ ~.,~}'`+ f'I.1.I~I~°,,.s"'
<br />LocATTON t Gf'~}~ I:'.'~~' i' ; Cl r3 ~. ~•• ~~•
<br />Form Approved.
<br />NATIONAL POILVTANT OISCHAROE ELIMINATION SYSTEM //NPDES/ OMB No. 2040-000
<br />DISCHARGE MONITORING REPORT t!DA4R) r:f ~ ~~tvi"
<br />PERMIT NUMBER DISCHARGE NLMADER }= •~- F ~ h;E~,! (~({k.} ~ ,:,
<br />~~~•~i°~L:••}~1` ~~L7i~~ "~ ~t~~r}'tiilk:cl=~t["~i ~~~?Y'~I•~.
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~ '. .C Tp ~,1 ~' .t ~. _ c #~••~• t,i::3 L . r c.t.:t~T~`Qr.s ~ti~ i X_.I •~..,.
<br />NOTE: Reed IrtetrucNom baton completing this torn.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO.
<br />
<br />EX FREQUENCY
<br />of SAMPLE
<br /> ANavsls TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />~~IG,. Fr:IV~ ~:r'}~~i•~1~'~ SAMPLE kit•i••i5•.sk'?• ~~h,' ~-:; ~••if•'.;•# :~•~.F•??•:r?f•# ;r..;c.ra.~.n:.:;l.
<br />t,,% j ~~}It,,j MEASUREMENT
<br />~• 4E: a ? ti %3 PERMIT ~ -tt x ~ # •zt R ~ O R T `, Iu' ~ = ~ -~ ~ ~ :~ # # •:a• ~i ~ ~ -n ~• •~• ~ ~ ~ # -tF :~• :3• ;: Pal C ~ i' v' I ~ IJ Fa ~.
<br />:~~'~"LUI'~}~~'r Ct~~r~~ ~,)t~_.U REauIRrrAAENT I~~1~;T h1AX Yut"_}=~ ~~••;:,~• t•1f~~•4T
<br /> SAMPLE
<br /> MEASUREMENT
<br /> aEaMiT
<br /> ItEQ(11REMENT.
<br /> SAMPLE
<br /> MEASUREMENT
<br /> aERM1T
<br /> REt2UIREMENT?,
<br />.......... .................
<br />.......................... .
<br />____
<br /> SAMPLE
<br /> MEASUREMENT
<br />-
<br /> ' '.`PERMIT :' _ .-- -
<br /> REQUIREMEN7
<br />_ .: __,
<br />_.
<br /> SAMPLE
<br /> MEASUREMENT
<br /> !`!'ERMIT
<br /> t'tEtiUIREMENT>
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ''PERMIL;!'
<br /> REr1uIREMEN't
<br />...
<br /> SAMPLE
<br /> MEASUREMENT
<br /> ;f!ERMIT
<br /> A~(2UIR[=MENT
<br />•
<br />NAME~TITLE PRINCIPAL EXECUTIVE OFFICER ' «rWr u er pen. q o lsw Thal mh doavmenund w ulaehlnenu were TELEPHON E DATE
<br /> peened ender my direction or auperrislon In .ceord.nee with a syriem desi`rled
<br />•••~
<br />r ~ ~ ..~ '~ f ~fTr~``l-t=.~ to srnrln IhN qu.NOed personnel Properly ether .M erNude the Infortnalon
<br />aubMtted. Baxd on my Inquiry of the person or persons who rrun.`e the system,
<br />!, ~. ""~'~'-// r~
<br />~
<br />~
<br />"'-
<br />1
<br />~
<br />/
<br />~. ( ~ Q ~ or those penoro dlrecty resporolbk for plherlrl` the Information, the Inforsrullon Z >r
<br />~
<br />~ t~ -.' • - ,.~.~_ j
<br />i
<br />_ ! f,e
<br />~
<br />~ C~_ ~ U 1
<br />
<br />y~~, // ' r ~,%~~~ f
<br />/~ ttt///
<br />submitted h, to the keel of my knowkd~e .nd betlef, true, .ccunle, .nd mmplete.
<br />I .m.wsn Iha Then .n slEnlnunt pen.ltle, for aukmittln
<br />rbe lnformalon
<br />~
<br />siONAI'URE OF PRINCIPAL° XECUTIVE
<br />/ ~
<br />i /
<br />r ! Zc.
<br />~~~ /~ ~ ,
<br />[..
<br /> ~
<br />, ,
<br />•
<br />npED OR PRINTED Ineludlnt the possibility of arse and Impriwnmenl for knowintl ridatlou /
<br />OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS ANO EXPLANA71oN yr ant vwLA I Ives Iffldermce sfi eaecnments Here/
<br />a t~,r 'F'f.]F,~}_ TI? 711 1.._~i';l'•}'1a" WI},...L T3E ;~1F~~`.'~:U, l~flil~ ~~1'ii.I::_+~:i'i_~: SG' a:i?~ Lt`lT ~,}a}::rl_3:I°.~ ~' ~~ <:=? (fi`x'}?~ '~'•~t°}3~ ~1=;F=1~ 1~=' E~l~t4'T~
<br />=w:~.i?"L.,~~IT3~..c ~t::l..l"~.?~ },...Ih'1~1` T-3F~aY fir' frJ~=a7'~I~I} ~f"iFd 'i~1~`~I~','~'..r`HR ~;:~)'~#'.4`i"--a~k~ 7. >~. 3.~ d~'P %~#-~.~ :~fi`~17 I. ~'y. w.''., F'. ~s ~'S.#3~
<br /> ~~~}'~If`•}"!"'i.
<br />- :~
<br />... ~ ~v r "r' «. I . '• 1 N e.-+ ".- . r .a 1.- 7 .J P 1• i . e-. 9 ~ . 1 • • . , « - : • ." , ...
<br />EPA Form 3320-1 (Rev. 3199) Previous editions maybe used. i •} _~ ~TILS.•1$$,,a~.4-p~•~fOrttl. A .,. F
<br />i \_ c., .J.. ~.-t 1• :. > "'~ lrZ~ C.1 ..~ -- :L 1:? ..:.t ,~.} G.
<br />
|