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PFAMITTEE NAMEJAD---SS flnchi& <br /> NATIONAL POLLUTAN HARGE ELIMINATION SYSTEM(NPDES) <br /> _ � PISCHAR NITORING REPORT <br /> T(DM?)F"Iy1Vww1Locqtjo nt I 11 4 <br /> AAMEPLEL - .OLLCa V , <br /> (1749) F F, <br /> .ADDRESS 1i � d SR MNE4( S t StORO4TER, � L PG I <br /> j�ERMITNUM]IiER DISCHARGE ENUMBER <br /> FACILITY WNITORINOPER'10D <br /> YEAR I MO DAY YEAR I MO DAY <br /> FROM <br /> LOCATION <br /> _L MINOR 3 <br /> i II 04TR3 <br /> • n I-: sh I STFV RN,:In N P, n 1P IfT (26,21) (22-23)'� (24-25) �(26-27) (2 NOTE:ReaO lniitructio66 OQ'fore completing this form. <br /> (3 Cmd Only) QUANTITY LOADING (4 Card Only) qUALITYOR CONCENTRATION i 1: i� <br /> PARAMETER (46-53) (54-61)' - I j ($446 NO. FREQUENCY SAMPLE <br /> (38-45) (46-53) 1) EX OF TYPE <br /> 0, <br /> (32-37) ANALYSIS <br /> AVERAGE MAXIMUM; UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> (62-63) (64-68) (69-70) <br /> 44 3", <br /> ,AL AND GREASE SAMPLE 0r'' !: <br /> 1 MEASUREMENT,, <br /> 1' <br /> VISUAL <br /> MIT o' -r K L Y A. <br /> �i40t6 o : :a U e.I. <br /> 0 PER V E!3 1 <br /> V 3 IT V <br /> REOUtREMENTff 4: <br /> 1. t,, U <br /> SAMPLE <br /> MEASUREMENTZ ji <br /> PERMIT <br /> REQUIREMENT E -4 4'r <br /> SAMPLE <br /> MEASUREMENT' <br /> PERMIT' & <br /> �REoul REMEI4 1�1 <br /> SAMPLE <br /> MEASUREMENT I':� <br /> PERMIT. <br /> ' <br /> PEOUIREMEN1. AC", <br /> SAMPLE <br /> MEASUREMENT. <br /> PERMIT <br /> 0 E OU�IAEUE�Tjt 1 <br /> S,01 <br /> SAMPLE <br /> ­ , 1:; <br /> MEASUREMENT <br /> PERMIT--,'- <br /> REOUIFIEMENT,ys Z, <br /> SAMPLE <br /> MEASUREMENT f <br /> PEAMIf <br /> REQUIAEM 1IiNj <br /> NAMEITITLE 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 /> Dv h ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG- <br /> AtA, 4�' <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT.SEE 18 U.S C. 1 1001 AND SIGNATURE OF PRINC(�AI'EXECUTIVE 9/ <br /> 33 US.C. I 1311;�=..da these slejutes 6ay include fiWa up to $10,000 0 <br /> TYPEDORPRINTED wlwtmah.. betwen6monl4sund,3years.) FFIC_R OR AUTHORIZED AGENT 1! AREA NUMBER YEAR MO DAY <br /> C <br /> I . , <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS(Reference allaffachmcnis .US"' <br /> 1" 1 <br /> OIL AWD GPEASE; SEE kC- OTNUTE Fl. !0- U 5"' PFP0:ET I-F FXEn-TIONS CL I! I M:7 r I T S is V 3 F; R i-ox T D A <br /> EPA Form 3320-1(Rev.9-88)Pravlous editions maybe used. (REPLACE411 EPA FORM T-40 WHICH MAY NOT BE USED) I i PAGE OF <br /> 0�0 3 211 C051 9_17 14 4 <br />