|
PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME CORP.
<br />ADDRESS ,'JI11l'd`._W IM F>""Y
<br />%J :C'f
<br />C
<br />--yy
<br />/
<br />
<br />FACILITY
<br />LOCATION i AT.?:
<br />. 'i t?-t• C""'?:.'IJ L'•-. ,.i .?.il;'I'"...tf",!?;"a?. ,=: 4t ':.=C' I. JF'f 11"`t"S i'",
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />ocj
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM L t ... tt ... TO .! r4„ 7. ,.
<br />Form Approved.
<br />OMB No. 2040-0004
<br />MZNER
<br />III AL_ 4 i s t%lr
<br />Itt?M I TR11f,I" r,!.d C',-? r_.rxl?4r 7 :1'1 I"t,
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY
<br />OF SAMPLE
<br /> EX TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br /> SAMPLE
<br />..;;°:3F:F
<br />.. :f F?
<br />3r7.a; +:
<br />r { e'?
<br />s E '4
<br /> MEASUREMENT
<br /> PERMIT t
<br />"t= L_I SN t ;s `I i i'c'tl tut', REQUIREMENT
<br />"i r:. 1 (.'hti?`•-?L.r ?;wi'fr;'.? SAMPLE .. ;hn .::r ,. .. ,,.:<.y, .:?. •:t•..:•:_., ! =...
<br />6?;^. C:0 VF.I e?,B! MEASUREMENT
<br />y t ;' (5 i', PERMIT
<br />a,
<br />31i'
<br />F.'f^ E'I I..}L'I'N:T (a#''Oti',!3 Vif L.UT REQUIREMENT
<br />T tf`.'1 SAMPLE
<br />'2'12lr r 0 T AL. MEASUREMENT
<br />' 713 Q3 PERMIT
<br />?,R:I'13 i =R;-J3 VPttLU-, REQUIREMENT i; ,: 4 •:6 t ;`? . i_. t" r
<br />Y. SAMPLE A a !5 ? :a:s ; ...c
<br />s. k, ?:} € bra!
<br /> MEASUREMENT
<br /> PERMIT ?; . t :r;•?f 3 # h .._ " L'>?v M 't?? t I,_....
<br />='! FL IiI:N"T GF--- 2)iS VA _L;I~ REQUIREMENT
<br /> SAMPLE C 03)
<br />;r,. w ... ' ...
<br />"'.'r'{i "°9 T €R; 'I" F=! .t't,tilT MEASUREMENT
<br /> :PERMIT 121
<br />t• .,
<br />•. ,•,
<br />.:
<br />,
<br />,t. .
<br />#"8 tifyl "s' OR 1F) S c" L,UF REQUIREMENT :tj " ! i 1'li'xr t; .• "I::
<br />l"..•f.e?I. i SAMPLE :i 3f :S 3 is i1 :•b+ s;i"t 'r is •'s i L?`
<br />. F` PtND COD ? MEASUREMENT
<br />rt.I " PERMIT it ` e : t •;i' , r, .. •, . 1 ° rt:'e it ;.` i°. t
<br />J
<br />? € I-US #',I 4 %s t...SL5 ` ?%L,, `),. REQUIREMENT }.7. •,. x ;'.t-• . aif W a : ? 1 ? (i .
<br />t
<br />-- ?...? r. r .'
<br />', L a>_ ?_., •E_ SAMPLE f# .: ! k t r? : w , .h.? ti..;i c'.3 Imo'? :c , :? si
<br />V 115kIAt MEASUREMENT
<br />7..11 PERMIT ..., .c l.w I?._.i'i..;1".. 1 a'=. ?t . .: ..i =r:°;• :; :t ?::. 'x"0 '..:•tr,',I.,
<br />i )"L..li.1' I`a•:" GROSS V.?it..?j- REOUIREMENT .. t t+?,-?• y...t {?'(:.,°-? .v. .:
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE
<br />
<br />
<br />'t y
<br />!
<br />`?' f
<br />A` prepared under my direction m• supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate the information
<br />! r
<br />.
<br />; r
<br />•,;
<br />?
<br />% submitted. Based on my inquiry of the person or persons who manage the system, ?•?,
<br />T
<br /> or those persons directly responsible for gathering the information, the information -/
<br />_
<br />!_,_.? f I? 4' ?(•
<br />( submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIV r t { ° 1l?lam i? /
<br /> 1 am aware that there are significant penalties for submitting false information, AREA
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY.
<br />COMMENTS AND EXPLANATION OF ANY VIOLA Iwrvb (Hererence an arracnmenrs nere)
<br />•'?'J, '? ..., .. :r, ..,.. ? ?'s?u ?c T._. 5... ? .'.. i.` i '.IS1 'viUW'I O2 ... .'.. _ C . s AG_= 9
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.
<br />
<br />;,rr!'?jL4 ?(:TI1T$ 15°a 4-,pert tOrm. PAGE ,_OF
|