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i <br /> PERMITTEE /ADDRESS (Include NATIONAL.POI I. T OISCIiARGE FI IMINATIr N SYSTEM(XPDLS) <br /> Facihtyl✓onlel nifdlJ,erenI) DISC H MONITORING REPORT /UaIRJ OMBForm No.204Approved <br /> OMB No.2040-p004 <br /> �-ME—; ..�i�1�L�L�.�.g..L�i��1l.r.�i__._. ....___.-_ 111_—__— fl7/9 <br /> f- —' (•1 NA L Approval expires 9-30-85 <br /> 0 <br /> ADDRE25BOX 1�rib_-----__—_---_ 5kLI .1 <UR=10YR24HR <br /> NUMBER DISCHARGE NUMBER <br /> --------------------- MONITORING PERIOD <br /> FACILITY <br /> �— ------ YEAR MO DAY YEAR MO DAY <br /> LOCATION FROM JJ TO MINOR <br /> (20.21) (22.23) (24.25J (26-27) (28-29) (30-31) NOTE: Read instructions before completing this form. <br /> (3 Card only) QUANTITY OR LOADING (4 card only) QUALITY OR CONCENTRATION <br /> PARAMETER FREQUENCY <br /> (46-53) (54-61) /38.45J (46-53) (54-6I) NO. of SAMPLE <br /> 32.17 <br /> / EX ANALYSIS 81f TYPE <br /> Lt >< AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX /ALMS ( YPE <br /> 69-70) <br /> P1 f SAMPLE -YrTTTTT* YA��1 <br /> MEASUREMENT <br /> 00400 1 0 PERMIT * ****** �papc o.5 ## {K** 9.0 NEKLYG A6 <br /> REQUIREMENT <br /> L= 1 * <br /> SULIDS9 SETTLEABLE SAMPLE ��pc�pc�p>}c spc 7a�7�Ja� �4Y TT <br /> MEASUREMENT <br /> 00545 1 (1 PERMIT REPORT 0,5- (ENT REQUIREMENT <br /> OIL AND GRLASE SAMPLE IK *l0 ak -_ * * <br /> FRE-W kXT R-URAV MITE MEASUREMENT <br /> 005 i6 1 0 PERMIT REPORT 10 ill E KLY AE3 <br /> ,L., REQUIREMENT DAILY MX <br /> FLUWP IN i PONDUIT' 0K SAMPLE �pc apL 7(F %F # >Oc sOLik * <br /> THRU TREA IMENf LAN MEASUREMENT <br /> 50050 1 0 PERMIT ' EPUKT REPURT ****** ****** ****** * ** ilt EKIYY S.T{lN <br /> VAI _ REQUIREMENT . <br /> INST M <br /> SOLIDS 9 VITAL SAMPLE <br /> DISSOLVED (MULL ) MEASUREMENT <br /> 70295 1 0 PERMIT REPURT REPORT Q TR LY, ;G AB.` <br /> ! i., _ 1 REQUIREMENT — . . <br /> 90DA AV MG/ <br /> OIL AND GREASE SAMPLE <br /> VISUAL MEASUREMENT �+ <br /> M PERMIT YtJ=I �IF* r ' * <br /> 84066 1 0 Klrf✓UitT ****** ;• 4iEEK►t�Y.V SUAL.. REOUIREMENT <br /> GROSS X * * <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> 11 <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIPT uN.ER PENALTY .F LAW THAT I HAVE PER—ALLY E—I... TELEPHONE D A T E <br /> ND AM FAMILIAR WITH T'NE INFORMATION SUBMITTED HEREIN AND BASE. <br /> ON MV INOU IRV OF TH08E N, IV BELIE IMMEDIATELY ESPONf10. POR <br /> OBTAINING TM! INFO IMDA T ION, I BELIEVE THE BUB T"Al T INFONM 111- <br /> /r S TRUE, gLCURATE A OM FL HTE, 1 AM AWARH THAT THERE ARE 810• <br /> N IFIC ANT ""A""' PORC BUBM-111 FALSE INFORMATION, INCLV... <br /> THE P0881BILITV OP FINE AN. IM PRIBON MENT. SHE It V.S.C. § 1001 AND <br /> u u.S.C. § ITI9. 1Pena1(ies unJlr these statutes may include fines up to$10,000 SIGNATURE OF PRINCIPAL EXECUTIVE <br /> TYPED OR PRINTED andJor tnaxitrlumiml)risonmentofbetteeen6-IIIOnthSand.5ycars.) OFFICER OR AUTHORIZED AGENT AREA _ NUMBER YEAR MO D - <br /> --- CODE AY- " <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all atrachmentshere) <br /> IF W UIStiHARGL OLLURS kL-PLKT 'INU i1I;,irriKRGE'* FLOW I MEAS.AS IwGq=MILLION GALLONS PER DAY. <br /> 2 PR1'.M FOK O&G. <br /> EPA Form 3320-I (Rev. 10-79) PREVIOUS EDITION TO HE USCD (RI-PLACES EPA FORM T-40 VVIIIC H MAY NOT DC USED. <br /> UNTIL SUPPLY IS EXHAUSTED. PAGE OF <br /> ci u6 t�c�/uu 2a ub-152 7 I <br />