|
PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />ClT
<br />NAME
<br />ADDRESS
<br />s . t 7
<br />FACILITY x,., r t
<br />LOCATION r .
<br />AT TN: E T Ell
<br /> Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT (DMR) M $ ftilOIR
<br /> 1 -
<br />5
<br />7 73
<br />
<br />, .3 ./ ...». , . ,.d ..i 71
<br />.D
<br />,
<br /> PERMIT NUMBER DISCHARGE NUMBER 1 x (+€ I-- •'%I-) ' i
<br /> -r G
<br />TCI':"I#3:1i-i"i 1-1 t.. ..-
<br />MONITORING PERIOD
<br />..
<br />YEAR M0 DAY YEAR MO. DAY .... *4 t. *
<br />- I Iv .r 1, I .;.; ' t€?E?G1~ I _!
<br />FROM TO <.. % r -
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0.
<br />
<br />EX FREQUENCY
<br />OF SAMPLE
<br />
<br />TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br /> SAMPLE •' ;: a;- tt.t, ...,.?;.?.;
<br />S _?.; }
<br />fl?iStTC
<br /> MEASUREMENT 3 .
<br />
<br />kr? t _ PERMIT
<br />Ef:1+}_tsi::'.i 1 ?j REQUIREMENT iI}tI}"#U}'°} rll?Ir,i ;;i c,i,+ }` }f,4;H
<br />
<br />' SAMPLE
<br />1 S
<br />I S
<br />2/
<br />CSP_4$
<br />`:il,`,zF
<br />E.}•iI_+, MEASUREMENT ,
<br />£>05 :.- % PERMIT iF 1?# :}ii i# # # fi # w: F F- F . _
<br />>._ _. Jr>}._;_z REQUIREMENT J-, DA G MX -e D A`,l MG/ L MONTH
<br />iS0}_`_.:•. :., rt; "" SAMPLE
<br />GU- 1
<br />??• ( c...,
<br />OZ
<br />2/
<br />g
<br /> MEASUREMENT
<br />OK)5. S i PERMIT !?? ! EiE Izir?### R,,?y..i: > i?lr? +"!
<br />E ; Lt3 iN 'JR ,.t :.:• Y'f'd .L; REQUIREMENT iyiErtr' 31I?f DAILY NX ML/L !''ot Tfl -
<br />IRON SAMPLE 'i k R t t H i.: >? c. rt. Q. ? f s ?? bW t c w
<br />TfITA}._ MEASUREMENT
<br />CaJ41" i PERMIT su # t # tt # RF 1?## tri Ir # r t-
<br />-------
<br />VALUE
<br />E 1 L43I'}?I>, 1? REQUIREMENT i :. 3QpA G DAILY NX UG/L_
<br />
<br />1
<br />` SAMPLE aS ?? Q? CSA?
<br />1 {aS
<br />LV I
<br />1 MEASUREMENT
<br />t? PERMIT i4 1 s t?ii # 7 i ?r k sx 2 !E sr i
<br />ET;-Li Vii:}a! r'0 . tia tYA}_#j; REQUIREMENT h r3 i:x t?I7A fit DAILY Mx tvji;,',/L
<br />Li"i;;. a is l ? S j. ;` SAMPLE i t.? i yrx , : srir rc•t s ;: R x r s yr
<br />?
<br />J
<br />S
<br />T
<br />AN I
<br />f i
<br />IS r Fi
<br />HRU TR MEASUREMENT 10. 4-3 * ! - fiJ
<br />'f U
<br />.
<br />__
<br />2_
<br />soc)` - PERMIT . b
<br />12 -
<br />}r}; i
<br />? i ;
<br />%s•i`}
<br />Lls
<br />FI LtJI REQUIREMENT 30DA A V9 DAILY MX MGTJ #3t IF Kt kn syw• t1df'
<br />_
<br />.
<br />,.
<br />,
<br />.
<br />t3 1°,1 i3 ':-. . . SAMPLE , r: 3t t ft f. +
<br />9
<br />j S1~ A1- MEASUREMENT \11
<br />JA
<br />r?k ii i PERMIT
<br />r REPORT IrtS b
<br />•*' k # # yy.
<br />n
<br />P
<br />w
<br />C•F' a }t-e VAIJUffl REQUIREMENT :
<br />,fi .
<br />.
<br />MElTITLE PRINCIPAL EXECUTIVE OFFICER
<br />NA I certify under penalty oP10w that this doormen[ : od all attachments were
<br />i
<br />d
<br />d
<br />di
<br />m TELEPHON E DATE
<br />` ///ryyy
<br />f ,1 ID
<br />R prepare
<br />un
<br />er my
<br />rect
<br />on or supervision in accordance with a syste
<br />designed
<br />to assure that qualified peejsonnel properly gather and evaluate the information
<br />-
<br /> submitted. Based on my Wquiry of the person or persons who manage the system,
<br />r^ p (?
<br />t or those persons directly responsible for gathering the information, the information
<br />` t ?l•-SI DE
<br />c
<br />{"i- submitted is, to the best ci';my knowledge and belief, true, accurate
<br />and complete. 1 7 . ( ?<: ,
<br /> ,
<br />I am aware that there ar
<br />significant
<br />enalties for submittin
<br />false information IGNATURE OF P ISIC6 UTIVE
<br /> e
<br />p
<br />g
<br />,
<br />s OFFICER OR AUTHORIZED A ENT AREA
<br />TYPED OR PRINTED including the po
<br />sibility of (}de and imprisonment for knowing violations. NUMBER YEAR MO DAY
<br />,.'I£>VMnnrzm I.7 Amu CArLmmm I IVIV Vr ANT VIVLA IIVIM. (nererenCO all afracnmenrs nere) -
<br />E DIS f_. s M I T WILL BE WAIVED FOR _,'10`t F, 2--*4HP ('REC I P I°VE-T-4 S'E-E. 1. A. 3, PG. 4, FOR , REQUIREMENTS.
<br />.. A01Pf.1TirG INSTRUCTIONS _ I. C. 10? .)G, 9.
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. '00242 OM70I * p firM. PAGE jOF
|