<br />PERMITiEENAMElADDPESS(IncludeFacdttyAane/L~rationiJ'Drf~erargi
<br />Ih~N NAME _
<br />__ .
<br />t
<br />FACILTY , ... ..-. ~ _ ..
<br />.' LCCATIQN , 1 _ . ..
<br />! , l 1,:.
<br />~ F, ,. . , ,. ~:. ..r^'i
<br />f
<br />i .~
<br />Y
<br />lava
<br />~N
<br />N
<br />I°
<br />0
<br />0
<br />m
<br />I w
<br />U
<br />ILL
<br />0
<br />z ' I~
<br />a
<br />c
<br />u
<br />~ '~ ,'j
<br />~.
<br />ji
<br />C
<br />~~
<br />~~~~'
<br />Form Approved.
<br />NATIONAL pCLLUTANT DISCHARGE ELIMII:A'rIDN SYSTEM ((N?QED) OMB N0.2040-0004
<br />DISCHARGE MONITOR{NG REPORT (Qtv7Rj -
<br />_i ..., _ w _.. }
<br />PERMIT NUMBER DISCHARGE NUMBER j - - ;-~
<br />N10NITflRING PERIOD _ ~ . . r-
<br />---
<br />.::
<br />YEAR M0, DAY YEAS MO..: GAY ~ , -'
<br />1 '':
<br />FROM TD .: ~(::- _ Y ...,;
<br />NOTE, Read Instructions before completing this form.
<br />PARAMETER I QUANTITY OR LOADING QUALITY OR CONCENTRATION ND, FREDNENCY
<br />DF SAMPLE
<br /> EK TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />r,l,.l 'SAMPLE : f:.Y.~ ~.:, ~ ~ y '~ :,
<br /> MEASUREMENT
<br />
<br />,.~;_ ~ _ ~f
<br />PERMIT -- ---- -
<br />-
<br />
<br />~ ~
<br />~T•' Iv ~ ~~ ns
<br />s.~ t 4 ~ _ i, r . J 1REQ~1 E NT
<br />~~ ~h .~ ~` t`
<br />~
<br />-' i
<br />~
<br /> SAMPLE
<br />~
<br />~
<br />:_+~,~`,fa~s ;'"t MEASUREMENT ~ ' ~ G~ar t
<br /> ~ ~
<br />,~
<br />~ ~t
<br />_i i"' l.a ~..wt _r~. z~ 'r r-lly tr 3~,
<br />w ~
<br />REgllf~:. ENT
<br />
<br />
<br />,~
<br />.. :..
<br />i i
<br />i _ ~ -air.,.
<br />~i.,~r ..m -
<br />~
<br />~I
<br />r r ~ s 3- SAMPLE _ .. r ,, z ~ _.;S .
<br /> MEASUREMENT
<br />,~. , , PE~1G11T
<br />
<br />.;, Wit:
<br />- - . , ~
<br />
<br />~ _, ,
<br />-
<br />
<br />~
<br />,,
<br />_.
<br />
<br />'
<br />
<br />
<br />,
<br />h~r s
<br />cT A.
<br />~
<br />p't'
<br />;.
<br />?
<br />i'~i~
<br />°
<br />i ~ REQU~NtEN7 ?'. ._ `~S ~..f L..
<br />_
<br />~
<br />r
<br />„
<br />~
<br />,,
<br />.,:r
<br />.
<br />?
<br />.~,
<br />~f.ar ~ ~l ry . SAMPLE
<br />
<br />~ _.
<br />_ - -- ._
<br />^:,
<br />
<br />`
<br />i, .`~,L r ~} MEASUREP,~ENT i ~
<br />t ~y i i P~~~AIT -- -- -
<br />r "'i,t~_ , , y ;f~,t`" ", r'~~i~i• iw
<br />! .., L, .. REQUIREPa1EPJT - ., . I _ _ ~ . , _..
<br />rl~'`.+_,. l:~, _,! s`;`T-::... SAMPLE s; ~P? r.: .: ,:: ~-:-.. ~: ~, t "r:
<br />«w ~'```y') MEASUREMENT
<br />
<br />.~ ::,
<br />`~ ~ ~ PERMIT ,, :.,. _
<br />
<br />~.n.. I . - ,
<br />w!- r~ f_t. L..-? .r," ., ~: _i ._ ~ ,, REQU1R~~ttENT
<br />~ ,1 ° s., ;.._ .r;~ ~- 1 ~,. SAMPLE ;: ~ ~: , „ , ,: ;r
<br />~.:~.
<br />,~...~.. ~
<br />
<br />,.z 1
<br />
<br />I
<br /> MEASUREMENT
<br />~ y. '~' PERMIT
<br />
<br />j,?:r '~ ~ .`Yf:+_;.; 'a~;_i~f~
<br />r' ;_ ,;.
<br />REQUIREfiRENT
<br />
<br />~
<br />..
<br />.
<br />~`+r" '
<br />- ~
<br />
<br />-_1--
<br />w SAMPLE
<br />""t~(rxl, "i~==.-: r ~•l;<I"-.~: ..,..'`'f~ MEASUREMENT
<br />~-r ~ 1 ~ PER)VfI,T --.--~
<br />. „ -,
<br />, ~ ~ ~~ _ _ ~ ~ ~ li
<br />'-. ~"i. ..l--""; _,'~~.~~r ` ._'~~:
<br />
<br />.. REQUIRE~AENT
<br />
<br />
<br />_..
<br />.,
<br />per
<br />, ,
<br />_: -
<br />;•
<br />..
<br />
<br />i
<br />NAME(I'ITLEPRINCIPALEXECUTIVEOFFICER Icertifyunderpenaltyoflawthattlnsdocumentandnllattachments~rere
<br />~ TELEPHONE GATE
<br />1I1
<br />W' l4MN fj(~ ~~, prepaz
<br />ed undermy direcfion or supervision in accordance Kith a rystem designed
<br />to assure that qualified personnel properly gather and evahmte the information
<br /> submitted: Based on my inqu'vy of the person or persons~n~ho manace the system;
<br />_
<br />J or those persons directly responsible for gathering the inrormalion, the information
<br />/
<br />~e D Cr'q?(p/j,7
<br />rrr ,7 submiUedis,fothebestafmyknowledgeandbelief,true,accurate,andcomplete. IGN UREOFPRINCIPALEXECUTIVE ~~ ~0~ - C O~ ~Y
<br /> [am aware that there ere significant penalfies for submitting false information,
<br />I 7YPEGORPRINTED includingthepossibilityofrmeandimprisonmentforlmmvingriolatians. 4 FICERGRAUTNORIZEDAGENT CODE NUMBER YEAR MO GAY
<br />~ ODMMENT5 aND ExPI.ANAIIUN Ur ANY vlVLAtrONb (Reference a!. attachments here)
<br />F-.i i
<br />,+' _... ~::~ _ . _ F,-:.. _ .. , Wit- _ ~ :; ~ _. ... .. _ _. _ _.. _.: . _ _ _ _.,
<br />,'
<br />~I t
<br />q ~ ~,~
<br />*,
<br />~la~~~
<br />
<br />~f !,~~
<br />~n 11
<br />``r~
<br />
<br />
|