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PERMITTEE NAMEIA SS llnclude « ' NATIONAL POLLUTA HARGE ELIMINATION SYSTEM(NPDES) <br /> FeabtyNamollocatit rent) ' r;.'�'•" •a•'r•�a. DISCHAR NITORING REPORT(DMR) <br /> NAME ' JU A L—O LL— 2 �.�nij lira, �— (2-16 (17-19) F ;— FINAL <br /> __;_ — 00000 0 :1 ACUTE WET TESTING FOR OUTFACE <br /> e PERMITNUMBER DISCHARGE t q " <br /> ---—----- —— —--- — =� — 4 MONITORING PERIOD t <br /> FACILITY <br /> YEAR MO DAY YEAR MC DAY <br /> LOCATION—_��- -__ `? +� ` FROM y x TO' MINOR (SUHR WC) !-jNTRS <br /> A T^_''. : D G N N I S S T E V E g S O fi P k i S ID E!7 ._ (20-21) (22-23) (24.25) (26-27) (28-29) (30-31) NOTE:Read Instructions before completing this form. <br /> (3Card Only) QUANTITY OR LOADING O,CardOnly) QUALITY OR CONCENTRATION FREQUENCY OF SAMPLE <br /> i:+; <br /> PARAMETER + (46 S3J (54 61) i (38 45) (46 53) (54-61) NO.EX TYPE <br /> (32-37) y I ANALYSIS <br /> AVERAGE MAXIMUM 'UNITS MINIMUM AVERAGE MAXIMUM UNITS (62-63 (6 LYS (69-70) <br /> E/F STA:Fi k 48H F ACU SAMPLE <br /> Fi I O D A P H h I A MEASUREMENT- Q D <br /> F G n 3 8 1 <br /> ' • FAE= .� � TR,zE Y `' � h0 0 ERMR P <br /> 0E0U1REMENr tSN M� BGSAMPEFF-UENT GROSS VALUE <br /> 5TAl&E <br /> 9614R ACU SAMPLE <br /> c P H A L E S P R O r E L A S MEASUREMENTS, 0 C.%+T-Rty &RA$ <br /> ikix&C 1 0 - 0 PERMi,,:. 1p +* RgP'OBT AEPORT 'ASS=O :, 'TRLT-' ,;RA8 <br /> tr <br /> EFFLUENT CR Y OSS qLUr :REQUIREMENT <br /> ;:� ;.+�• c" '��"��' - <br /> SAMPLE 4`'u <br /> MEASUREMENTGi <br /> e* PERMR t v '`^`Fri <br /> 'REQUIREMENT .' tP' t � y ^'' RI `'"'''J'' r.' ter.' �s w+ # l.. ,�•', 3: r,' <br /> t. <br /> SAMPLE r <br /> MEASUREMENT e <br /> PERMIT" <br /> 'REQUIREMENT >^- fys. <br /> SAMPLE elt •,�' <br /> MEASUREMENTj�, t . ,. <br /> = PERMIT <br /> QUtREMENT Ter• �.y :«ate- 'v: �? -+ . Yr r-,".s�,'' .'.4 <br /> 1tE w(. <br /> - r r. <br /> SAMPLE g '^ <br /> ^ 4 _ MEASUREMENTS' <br /> 1/ t4, tt y PERMIT <br /> IOC REQUIREMENT a� kt d .'F+•. �'' 't: rCi ,' + ,xy_ P (1 ;� �, ', °i�9t>3 l.' x H, r <br /> °• 2 <br /> .`.. f SAMPLE �' •+' Sk 2. - V <br /> MEASUREMENT 'S <br /> J PERMITS^it 4'` �ri` 7.: + � .yw� .+ } •rwl,' p <br /> v REMENT '' `° C3. ' ..' '^bY .t 4 :ir ^.$"• 'trQ i } 't •:i;' 3 ,fi! ;1 : , !t I <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE DATE <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN;AND BASED <br /> T ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> Y)A h YN►1 L OBTAINING THE'INFORMATION I BELIEVE THE SUBMITTED INFORMATION :+ <br /> ` �• IS TRUE,ACCURATE AND COMPLETE. i AM AWARE THAT THERE ARE SIG- q LMYi�O1�TKH a tej NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING /Q� ��+Zs3 /f a Zvi THE POSSIBILITY OF FINE AND IMPRISONMENT.SEE 18 U.S.C. 4 1001 AND SIGNATURE OF PRINCIPAL EX CUTIVE !o / <br /> 33 U.S4. 4 13%liaetrahies under them statutes may include fines Np to $10,000 <br /> TYPED OR PRINTED andormia*mmimprbonmentof between 6 months and Jyma.! OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENTAND EXPLANATION OF ANY VIOLATIONS(RefemceaUattachmentshere) <br /> I <br /> SEE PART I .d-: OF PERMIT FOR D iXtS OF TEST PROCEDURE. REPORT RESULTS OF IWC TEST AS "MINIMUM" ANO 50' <br /> MORTALITY TEST 15 "MAXIMUM" AKD� ATTACH ACUTE TOXICITY TEST REPORT FORM. TO DMR, COPIES OF ALL INfORVATIO:. <br /> fi-da�'PrdV1oU edltlons maybe Used. (REPLACES EPA FORMT-40 WHICH MAY NOT BE USED.) <br /> PAGE <br /> ;, ; 00006/900514-1715 1 <br /> OF <br />