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PERMITT•E E NAME/ADDRESSr6trludrFarilih \itmr.'InrntinniJDiJjrrrnlr <br />NAME <br /> <br />ADDRESS ; ? I NE <br />4 <br />1 <br />4 CUW-Ji"Y RIDAD 120 <br /> . <br />. <br />3PERUS C;0 f <br />FACILITY ;G Cf!-:. MINT <br />LOCATION . - ,- 3P ER 1 .'j <br /> tit ftEi)i ? ZKI, !'TINE ENIGINEf <br />F, m Approved <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) C'Vii Nc. '0 40-0004 <br />r, <br />DISCHARGE MONITORING REPORT (OMR) :,i T <br />PERMIT NUMBER DISCHARGE NUMBER r <br />TO HAY <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY TT <br />- - FROM TO L- 1) NOTE: Read Instructions before Eompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> EX 0'C TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - L' • E:5 ! : ,. r a ?y .. ... .. <br /> REQUIREMENT 1`d:? t f7i+ ?i _ ;•i^:: :: <br /> SAMPLE ,?, <br /> MEASUREMENT - <br /> PERMIT ` <br /> REQUIREMENT <br /> SAMPLE i <br /> MEASUREMENT L <br /> PERMIT \ I <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I „rtir nndrr p nnu, of lnw chat wi, d.nomrm :n.d all an,i,hto,nt+,,,n r '?' .. TELEPHONE DATE <br /> d und <br />m, dn <br />lanc <br />,ulh d . t 1 t <br />eA <br />r <br />r <br />cti <br />n r ' <br /> p <br />rpa <br />e <br />a r <br />, <br />n <br />q <br />e <br />Cn 1 <br /> yn..h6 d peru,nml l r lwrh gAhar <br />_' ,uhmmnl. Ikrw•J nn m, ingwr f Ih fw rw n r Iw•r,nn. a ho uema th l m. ? ? t L2 ? ' I <br /> <br />ur lh.w• Ir•num JuralA rr+µm.itrk lot ?utha-rims lha inlonnabnn, Ib. inf ,rmali.m <br />•-'? <br />\ ` n ,/ <br /> w .,iiim i+. u, the Ina of m, hnowlcdgr.md Iw•lirl. Inu.:acurun•. and n.ngdelc. -`? ?;;? ?_ tr.? j <br /> Th <br />' <br />lG <br />f <br />iui <br />J <br />1 <br />t <br />i <br />if <br />l <br />b <br />I <br />f <br />tli SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> xm aware <br />hen .u <br />prna <br />,. <br />or ,u <br />+e m <br />nrnr <br />on. <br />al <br />r + <br />?n <br />n::m <br />m <br />n? <br />: OFFICER OR AUTHORIZED AGENT AREA <br /> <br />TYPED OR PRINTED im•hwin-, the rlnltp of fin, and im ri,nnmenl for Anoaing,rolatinn+. <br />lun+ P NUMBER <br />CODE YEAR MO DAY <br />GUMMEN I S AND EXPLANA I IUN Ur ANY VIOLA I IONS (Flererence an arracnmenrs nere) <br />'ECIP EVENT SJII•_IECT TO SURUEN OF PROOF REQUIREMENTS IIN <br />:JIV;.^IUN WITHIN 48 Ht]UR!?;. <br />TO THE <br />EPA Form 33201 (Rev 3/99) Previous editions may be used ='HOC' Fktiiais- # Pats iirn?.