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FERMITTEE NAME/ADDRESSRieer4s-OryN..?L. .to .(/D(06nw) <br />NAME <br />ADDRESS <br />U. BOX 187 <br />TG r CI <br />FACILITY ''PER H I NE <br />LOCATION - ' I G c l <br />YMOND G. DU BOIS, PRE' <br />NATIONAL POLLUTANT 04SCHARGE ELIMINATION SYSTEM IrNPOESI <br />DISCHARGE MONITORING REPORT IDA4RI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />8I62? YEAR MO. DAY YEAR MO DAY <br />FROM TO <br />GM <br />MINOR <br />(SUBR ,JC ) <br />F - FINAL <br />DISCHARGE TO SAGE <br />Form Approved. <br />OMB No. 2040.0004 <br />RFEK <br />IOFAT <br />NOTE: Road klstrucdone before cornplating this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX S TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSI <br /> SAMPLE <br /> MEASUREMENT <br /> -t <br />7- c _ 1 F4 .a <br /> PERMIT r ? .. <br /> REQUIREMENT hi I N I Hu;.'r- MAX I MUM <br /> <br /> SAMPLE _ <br /> MEASUREMENT <br /> <br />.5 1 0 PERMIT <br /> <br />'It' -11, Will <br />_?r It Mir <br /> <br />_ <br />_UENT GROSS REQUIREMENT f A''lU IL'( MX - •' <br />- SAMPLE <br />MEASUREMENT <br />' <br /> I., <br />1 0 PERMIT / <br />UENT REQUIREMENT ` j INST MAX CENT <br /> SAMPLE <br />TRf- Pi MEASUREMENT ! <br />l PERMIT - <br />!-' -:`:T REQUIREMENT 30DA AILY' <br />- SAMPLE <br />T MEASUREMENT <br />5 PERMIT !I : <br />' <br />.. ...._ . , ..: u <br />? ='._UF i, REQUIREMENT SODA AV(i = r <br />MX t•i.. <br />17 _ - SAMPLE y. i <br />?Z?" MEASUREMENT <br /> PERMIT " <br />' i._0ENT I - REQUIREMENT :--PAST MAX <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TiTLE PRINCIPAL EXECUTIVE OFFlCER I nrtrly u n no ty o law that thh docvmrnt and all attachn,rnts wen TELEPHONE <br />prepared under my direction or Pullet lflon In accordance with a system designed DATE <br />to assort that quallMd penonnet properly galher and evaluate she Information <br />i .. sobrritted. stand on my Inquiry of the person or persons who manage the system, <br />• ?/ - or throe parsons diren/lr mpoalbk for gothertrrs the Inrormadoa, the Information <br />" <br />submitted K to the best of my knowledsn and bew. true. a rate. and complete. <br />MUNCWAL EXECUTIVE <br />! <br />i <br />` I am aware that than an slpdnmat penaNks for subnitttrq raise Information. EIONATVRE OF A A <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED Incfisdln[ the posdbisty of nee and Imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CAE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reference off oftlcnmonfs nary) <br />F SOLIDS LIMIT <br />"13 <br />APPLIED FOR <=20YR, 2'4HR <br />PRECIP <br />EVENT- <br />r <br />L. <br /> <br />' _ „ ' -.?• ` _ <br />3199) Previous editions may be used. <br />m 3320.1 (Rev <br />Fo , a;?t?3]s a.4-Qar[;fprm. PAGE OF ` <br />/ <br />. <br />r <br />EPA