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PERMG E NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved <br /> ..� ame/Goc If different 1 DISCHARC ONITORING REPORT (DMR) IMB No.2040-0004 <br /> NAME__ ,• a ;h){-iti K� •1 17-19 <br /> (' > spires 2-29-84 <br /> ��--(Tq�a •i:l•J A I 1'-1(} ------------- <br /> ADDRESS <br /> 15 ( � , 4 r: t• r� (.i" <br />---- 1,1t r '�--r�-��M <br /> WFMZ T J• I r PERMIT NUMBER DISCHARGE NUMBER <br />-----�'t-- 4' --------------- <br /> i i— —————— MONITORING PERIOD <br /> E&Q•=------_..-------------- YEAR MO. DAY YEW I M DAY <br /> LOCATION I I I FROM TO <br /> ..................... <br /> (20-21) (22-23) (24-25) (26 ) (zs-z9) (30-31> NOTE: Read Instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER. (46-53) (54-61) (38-45) (46-53) (54.61) NO. FREQOUFENCY SAMPLE <br /> (31-37): I EX ANALYSIS TYPE <br /> ;^t <br /> �+ lg AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63) (J64-68) (69-70) <br /> f 1.0Ni (E1"iTLU'ENTJI SAMPLE <br /> C <br /> MEASUREMENT # �t * yt * �! •h k +• 4 + <br /> 1 <br /> IaltauiaMrIlerlT 4" 4, .w 4 {7 T <br /> TOT <br /> SAMPLE �� <br /> Z• i.'=•.• <br /> SO IDS S 1 V 1 u: 5US:P MEASUREMENT <br /> tE PLUENT)i I►1CrtMIT <br />{� + IeE4utR)sM)�IwT 1 :. aIt 'K <br /> ,, ' SAMPLE <br />!RONJJTUT4L MEASUREMENT +• > k a + r 1 <br /> I IiftRMIT ' <br /> r3 ItEQV 11tEM1lt�IT 4 , q <br /> uLS <br /> SAMPLE 1 ) <br /> PH jF I EL I MEASUREMENT k i Vr <br /> PERMIT <br /> 0 4 0 0 4, r Is 1;SAMPLE 0 <br /> OIL K 111E[;ASE MEASUREMENT A 1, 1 J7 <br /> V I S U A L t PERMIT <br /> REQUIREMENT 4r yr 0 >s t <br /> of V? <br /> CONCIOCTI •Ity <br /> 8,10 MEASUREMENT >*• <br /> TGS (FFF1,1JE�JT) PERMIT <br /> 7 U 4 0 1) REQUIREMENT $ S 4X ea k A tk �e 7k 1 1r ' JfF) :.Yi <br /> y�,'1;//[d Ei46,eiE- SAMPLE �► CJ W/ t IrL: J 17 <br /> MEASUREMENT i <br /> 00 5"401-50 PERMIT <br /> itagU IREM ENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED 1 <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED (j i TELEPHONE D A T E <br /> jr5' t� ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR / ( <br /> OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMATION 1, 10 <br /> /♦ t <br /> n IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG `�� jr J Y L•I" °1.j4� <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING — Z } �- ,,- / t5 THE POSSIBILITY OF FOR <br /> AND IMPRISONMENT SEE 18 USC 1 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE VJ <br /> 33USC 41319 /Penalties under these statutes may Include fines up to flo MNl <br /> TYPED OR PRINTED and'nr maximum imprisonment of hetween 6 months and 5 vears I OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODEI <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> IF -h 01,SCNAPGP UCC�JR ;f- f) il;, f 1, T;41 ,. I i I .,., E rI F 1 , 1r: ( 11t t .•r 1., <br /> S E F PF F?MTT F (U+� L IMI7 r;L , , (, c t I• G T y s , i r. <br />'A Form 3320-1 (RSV. 10.79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> UNTIL SUPPLY 18 EXHAUSTED <br />