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PERMITTEE NAME'ADDRESS rlnc•luclt Foeflfn Nume.L.uuttnn il'UijJ'rrrnt/ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />NAME _ I ~-~ ~,_ ~,~~ 1 - DISCHARGE MONITORING REPORT (OMR)
<br />ADDRESS ~ ~ I NE
<br />i7 n.`~ tlltit ~' AT ?'7N R ~ PERMIT NUMBER DISCHARGE NUMBER
<br />~.~GTGf r
<br />FACILITY MONITORING PERIOD
<br />E. L la.
<br />LOCATION - .; ~ ;~N YEAR MO DAY YEAR MO DAY
<br />FROM TO •
<br />_ ~E ,~_
<br />Form Approved.
<br />OMB No. 2040-0004
<br />- ~
<br />NnTF• Rwari Inrttnu:tinnn hatnrw emm~lwtlna thls form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREDUENCY SAMPLE
<br />
<br />EX OF
<br />TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br /> SAMPLE ,.. ~. r
<br /> MEASUREMENT
<br /> PERMIT ... t: i. # t'~ - -c .~_
<br />_ _ - ~ REQUIREMENT I.IIRII'^t'^' MA?'It"1U1'1 '.'
<br /> SAMPLE •• `- '
<br />.. MEASUREMENT
<br /> PERMIT r•ii## ice-ut-ttt~ :~r_ ##3`srfi •-~ t t..t: ~1-P',':
<br />- - ~ .. REQUIREMENT 3:iL:'. , ~ :•1 A AV •iC~ ; MQNTr
<br /> SAMPLE . x ~ ~ -
<br /> MEASUREMENT
<br /> PERMIT •IF•k k 3 #- L: i # it
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<br /> REQUIREMENT - ~ ~ Y I~~`~ I L ~' f`i .X "iON'T ;'•
<br /> SAMPLE ` .
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<br />_ MEASUREMENT 1
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<br /> MEASUREMENT
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<br />"~iFi" Tft~RTMENT PI_, MEASUREMENT
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<br />~: ::: - . ~ ~_ . MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXEC VE OFFICER I crrtif} under penal[}' of tae [hat this dr~umrnt and all attuhmcnG were
<br />di
<br />~ TELEPHONE DATE
<br />
<br />~~/4yrj ~ , •; ; ~ti= ~ ~/.- Q ~ prepared under my
<br />rrcticm or supcn
<br />ision in acaudance with a system designed
<br />to assure tt[at gt[ahtied personnel propttly gather a[td cs'aluate the infnnnation
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<br />(^ submit[cd- Based on my mgwq• of the person or persons who manage tht system,
<br />or those peraons directh' rc,:ponvble fm gathcnng the information. the information ,
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<br />f $IGNATURE OF PRINCIPAL XECUTIVE /
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<br />mcludinc the possibility o(fine and imprisonment firr knowing violatiu[ts OFFICER OR AUTHORIZED AGENT AREA
<br />NUMBER
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<br />:~.'t.,:; LIMITS AF'PL.. ,y. j, ,; ... ,_; ::: ;. ~.rT(-
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