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PERMITTEE NAME/ADDRESSQweYlsF~etbryN~r~Leeurenl/DlQirenr) <br />NAME ~~~I~i°~I~ ~'~.~{all~ltilG`r iI~IC. <br />ADDRESS ~TF~2F~~P~R i"i1:1~1~°~-. <br />f Ci. k3 C! 3i ~ 8 ~7 <br />Gfi~~t~~ CQ Ei1~~~ <br />FACILITY (I~~~~~~ ~~lit~l~ <br />LOCATIONC~F~~~ ~~ <br />''LEa~.e <br />~S <br />tt^^~t SS~~ <br />iPi~i I (~I: ~~iY{~CJI~ltl f~ <br />tt <br />~~11 99~~r^~ i~rr~~ <br />ta. ~Q.j A:i4tiSr r"Y'1~.C3~V1~ <br />Form Approved. <br />NATIONAL POLLUTANT OISCNAROE ELIMiNAT10N SYSTEM /INPDESI OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT /DA4R1 ~ i ~~~.~ <br />~c~ac~~ry:r. ~.s c~~s ~ i ~u~~a .~c ~ <br />PERMIT NUMBER DISCHARGE NUMBER ¢' - g" ~ f~lAL f~iC3i~~A"f <br />MONITORING PERIOD DiSCM~RG~. ~~ M£~1=t~~ ~UL~..H <br />YE R MO DAY YEA MO DAY <br />FROM .a ~ {.t TO ~: ..... ### sau ~rISCH~f~O~ ~~ #'~"~ <br />NOTE: R~~d II»trucdtxa b~1tx~ complytiny thb town. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FaEOUENCr <br />OF SAMPLE <br /> <br />YPE <br /> ANALrst3 T <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />D F~ ~~~ SAMPLE ##i&YF3~# ( ~~d• 3 #####~ ?F~i.L#### #xF#xF#3E <br />~ i r~^(,J~(-, MEASUREMENT <br />t3~C?6c~ ~. D f~ PERMIT #-t~#~-## ` ~'~, =~. ~##### it•;#• ~` ##~#3f•~ ### ~~ ..,~ Z~it~A <br />~~~LU~~a~- ~~a~s V~LU <~~Ql11REMENI' <br />::,..,........ . Ii~~~i' r~~~ ray=c ~:~#~ r~~~~~c, <br /> SAMPLE <br /> MEASUREMENT <br /> > PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ~~ <br /> PERMIT Q . <br /> RE¢UIREMENTr <br />_. ~ <br /> SAMPLE <br /> MEASUREMENT <br /> `<PERMIT <br /> iiEt1UIREME <br /> SAMPLE <br /> MEASUREM T <br /> 'PERMIT .:: <br />' ~ <br /> a~~viR~M~~tt' r..- <br /> SAMPLE <br /> <br />MEASUREMENT / <br /> .: .PERMIT .; <br /> REC1u~itpMEN'1' <br />................... ...... <br />.:........................... <br /> SAMPLE <br /> MEASUREMENT <br /> ::PERMIT <br /> AEC]UIREMENT <br /> <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 ttrtuy u er pem t) o hw Ihal thb doeumenl •nd sll Ntachmenb went <br />pnrpared under mr dlreetlon ormper.lalon in rccordrtnee with a erstem desi`ned <br />TELEPHON <br />E <br />DATE <br />/ <br />n ~/ ~ <br />~a <br />t` to uwre thN qusHOed personnel P~Pe~I 6nther and eraluNe the Infornullon <br />whmllled. saxd on my inquiry of the person or penoro who mannee the trslem, - ~.~J~ Cr'L~ <br />r ~ <br />/ <br />~~~ G <br />F ` v <br />ff~ J <br />~77rrr or lbase penoro dlrectl~ resporolbk ror ptherl~ the Inrormotlon, the Informstlon ~i 'J/ <br />, ~/ /' ~ <br />~ f ) <br />~/` <br />~ <br />S . r{~ ~'~ / C~i~~ / / ' ~,f• r <br />C-~ <br />submlltad Is, to the pest of m~ knowledge snd betler, true, oceurale, rnd mmpkte. <br />1 rm aware Ihst there sre sl <br />nlllunt <br />emltles ror <br />uDmlltl <br />hl <br />I <br />f <br />tl <br /> <br />SIONATLRE OF PRINCIPAL EXECUTIVE <br />` C/ ~ <br />J/ <br />~a J-YJ'G <br />C_./ <br />, ~ <br />Il <br />. <br />~ <br />' ~ <br />p <br />x <br />n <br />a <br />n~ <br />orm~ <br />on, <br />Includi <br />th <br />ibiill <br />f e <br />and I <br />b <br />l f <br />k <br />l <br />ld <br />U O <br />AUTHO <br />I C <br />E NUMBER YEAR <br />OR PRINTED <br />TYPED nf <br />mpr <br />e poss <br />y o <br />ne <br />onmen <br />or <br />now <br />n` r <br />a <br />ons. OFFICER <br />R <br />R <br />ZED AGENT OD MO DAY <br />COMMENTS AND EXPLANATION OF ANr vlvLn 1 lens IRtrl~rtrnc~ tr/1 •tr~cnm~nrs ntrr~/ <br />T~5 u TOfTs~L .a.1;flIV Li~'ii?a wIfLL i3~ WAii1~57, 2~ S~"I•TL.~:~,I~Li: SC31~~'OS L.iE'iT AF'P4~i:Ei? F'®R <;=iC;YF~, 2~lii~ ~'R;ECiI~ ~~1~1V~'-- <br />5E~ I3U~dL)E~ ~:+F' t'RflQ~' R~~slliE$~i't'..:iV"i"~ UI.3T7~f-i i. s'~. ~. iiD~~"-+ ~~36~fiY'l")RiPIC --~ i. Ei. 2. •}~LS.ig, <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. QQQ~~Q ~ la~~)~4 ~~,r~f4rm. PAGE ~F <br />