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^if <br /> NATIONAL POLLUTANT Ott E ELIMIr1ATtOrJ SYSTEM ( aid i <br /> i DISCHARGE ML �tNG REPORT � <br /> f <br /> I <br /> INSTRUCTIONS <br /> 1. Provide dates fur period covered by Wit Mad In spaces malted"REPORTING PERIOD ' - <br /> 9. Enter repotted minimum, avenge end maximum values under"QUANTITY"and"COtiCENTRA710)i'° + <br /> Do not enter values in boxes containing <br /> In We units specified for esch parameter as appropriate. <br /> 12>0 1«Isl HIT-Isl asterisks. "AVERAGE" Is Wf8rc Computed over actual time discharge is opantinl& "IiAZD1UY <br /> `-' r end"MIN1M1lUM"are extreme values observed during We reporting perio6 <br /> 1 C � �;O/ 1/z'l3 Sperity the number of analyzed samples that exceed the maximum(and/or mrnlmten•a apprnpdaN)pem%it cm%ditions In thecolumns labeled"No. Es." It none,enter"O".ST UM OER Di5SIC LAtITU OE LOHGITUDg q, I;peelfy &eyuency of enolycis for eachparameter as No. analyses/No. days. (e.g.."3/7"is egUlYr L�m_ Icnt to 3 analysea performed every 7 days.) If continuous enter"CONY." <br /> - 12o•211 112-231 124-1e1 120-271 124-x91 t30.311 g, Specify sample type("grab"or"-hr. composite")ea eppllcoble. It frequenC7 One COntlauOYa. <br /> 7 t enter "NA". <br /> -y 7 TO �:7 d A/ 6• Ap,ropdete sigcature is required on botlotg of We(orm. <br /> REPORTING PERIOD: FROM I.t_ _ 7. Remove Carbon and octal,%copy inr yoot records. <br /> '.{ YEAR MO DAv YEAR MO OAY A. Fold along dotted lingo, staple and mail original I*office specified to psrmlL <br /> (I cud only) CONGENYR QI'ION If"Mut11CY gAwPLi <br /> - (.1 e..a only) QUANTITY of <br /> 100•1 Ise-°]I la�aD 102-0311ea-°D IAO•etl n°-t ll * <br /> PAAAMKYgftMINIMUM AVERAGII MAXIMUM UNITS !X MIftIM11M AVERAGE MAXIMUM YMITe [K ANALYSIS - TY P! ( !, <br /> -------------------- <br /> •�ERI�IT - � i <br /> cONDI"ON .d. <br /> r160ED 1 <br /> 1". <br /> i <br /> Cy /� r�',G p[ScII •/�L"G v I1f 6— /DEDT <br /> i <br /> CONDITION t <br /> A[PORTED `• <br /> PC RMIT Ik' <br /> t CONDITION <br /> } R[PORYaD 1 �f <br /> ._j PiiwM1T I i�' <br /> CONDITION !! <br /> REPORTED •-1 <br /> l <br /> i f <br /> P EwM\T <br /> i�fF CONDITION - 1 <br /> t f`- <br /> , � iE <br /> ;. PERMIT <br /> CONDITION <br /> �i RaPORTio <br /> PERMIT <br /> { CONOI TION �C} <br /> 'I NAME OF PRINCIPAL EXECUTIUR OFFICER TITLE OF THE OFFICER DATE { .L�y�(Nltir <br /> 1 cartlly%hot!am lamfllar%vlth the fnlormatton connllnad In yila lI� <br /> CX/:CuT/VE ViGE Pi4'ESiDEN! 7 % O tf 2 / f°p°rf and that to tha beat of my kaowfedpo and bend such lalar t <br /> matloD 1e tN1.complaih and aCCUtata. SIGNA7U R!O/PRINCIPAL[X[CUTIVg F <br /> i RF�eV,j 3 JOHN YEAR OFFICER OR AUTHORIZED ADS PIT <br /> FIRST <br /> MI TITLE <br /> MO DAY �.. <br /> '1 LAST PAOII O/ I ; <br /> CPA fun 3320.1t10.7�1 ORIOINAI <br /> i , <br />