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FEALUTTEE NAME)ADDRESSt7a"For*#YNaaWlor4WI-t(Dl -00 <br />NAME ' <br />ADDRESS <br />?1 STA i L HIGHWAY 13 <br />":KER CCU , <br />FACILITY OWYO NE <br />LOCATX)N E K ER L3 816, <br />ELLY D. :,ANDERS, VP OF OPS <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /)VPDESJ Form Approved <br />DISCHARGE MONITORING REPORT tDMR) OMB No 2040-0004 <br />PERMIT NUMBER LDSC:.::A:1OE NLIIdeEN - '' <br />POND TO T4, -_: <br />MONITORING PERIOD <br />YEAR 0--i DAY YEAR MO DAY ` <br />FROM ;• TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. MEOVENCY SAMPLE <br /> <br />EX OF <br />Y <br /> ANALYSIS PE <br />T <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />L tJE ' ' REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />1 veII) under penally-of sw that this document and OR attachmenu were / <br /> <br />, <br />NAM TLE PRIM PAL EXECUTIVE OFFICER . TELEPHONE <br />d <br />dl <br />/f <br />r <br />bsi <br />I <br />d <br />DATE <br />pnp,re <br />an <br />ef m) <br />tee <br />On o <br />supen <br />on <br />n accedencewlfh , 3)atemddgned <br />1 <br />to assure Choi quaNMd per»nnel P. a".ly gather and evYuatt the Information <br />"'limpid. !wd on my Inquiry of the person o, persons who manage the worm <br />; _ <br />or those persons dfrectty responsible I" gathering the Intonrustlon. the Infor <br />nalton <br />? <br />( <br />submitted K to the best of m7 knowledge and b*W. true. accvrtte. and complete. <br />10. aware that there an significant penaldn tar subm/ttin <br />tabor Informati <br />SIONATURE OF MIINCI?AL EXECUTIVE .. <br /> g <br />on, <br />TYPED pRWd,p tneluding the possibility of nn..nd imprttonmrnt for mowing .Io1,Uorn OFFICER OR AUTFtoRIZEO AGENT BODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference eH attachments here) <br />4{t?tc:r} t, <br />75{? ?Fj?( fFt ?tlr^•t.)T i? r'(. ?TP'ii-t",. ?P ?I../??M1? APP <br />EPA Form 3320-1 (Rev- 3/99) Previous editions may be used ThiS iS 8 4-pets form. PAGE OF