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if�rTEE NAME/ADDRESS{include NATIONAL POLLU— T DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved <br /> Facility Name/Loc different) DISCHJ MONITORING REPORT(DMR/ <br /> lJAME_�` } h` t• `. { r ( � t' OMB No.2040-0004 <br /> 17-19 6 — f d <br /> Approval expires 9 30-85 <br /> 14' p <br /> 3�;j1 '+;�'1 tf,![�}'A1 i� i .`�t� �_- PERMIT NUMBER DISCHARGE NUMBER <br /> MONITORING PERIOD <br /> YEAR MO DAYI YEAR MO DAV <br /> FROM <br /> A fl', .'1m rl.'"1 ' f' - 1` i — (20-21) (22-23) (24-25) (26-27) (28-29J (30-31) NOTE: Read instructions before completing this form. <br /> • 1 i 1 I (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETffR ( (46-53 NO. FREQUENCY SAMPLE <br /> J (54-61) (38-45) (46.53) (54-61J P <br /> (32.371 ( F EX ANALoYSIS TYPE <br /> 1 I ( AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> >< 62.63 (64-68) (69-70) <br /> ,- <br /> "{ {{ SAMPLE ' z. . d ;J:.Ce •a`�.s <br /> 1 I f ;. MPtEa6AQ,SUU4RREEMM,EEMNTT <br /> � . F!yy <br /> • ;a's'R/`"r',�-i."w^'>�' ';ij;,;/ a.,r /„r,`4;,,,. 9 r �/;;" ';rr;v ' i' iw'e M0 Ell <br /> 6 <br /> a" 3 :, # w:a F ; ,Sid„, Hr.>' y//' r •i <yj%/,w> ..'� '• i✓'.� <br /> rkc.t.FA SAMPLE r'tM ✓ �- " ;i-- %ir�1^�r'1 <br /> i 6� `�t ,�• �,' , t MEASUREMENT + - <br />'JV':J 9 Ifk {L titiSi�' �., t PERMIT s °Jj ry ,`3•:'_ ' .b +bY� ;�: / w< � � s�%ro, y: ti'yN ••f/ <br /> REQUIREMENT = gve y 7►�" :` ,,,;i" r�M „ <br /> y g4 <br /> IL <br /> AND GREAT - SAMPLE >;'`6't - 4 - i' r r,- � Jd tp-r-%li a~M <br /> A MEASUREMENT <br /> EM[iNIN x, iu;"�" .''y, '; ht:i;;:gim ?;f k�•r-'' tt3 v F ,''„;%'F'i;;;Nyu'ri 'fi F�f^ '" ' %a1y f y.,"� u%v;,iEQUtR <br /> t/4�/qqa .;, <br /> .t,�DN j"' dTAL- SAMPLE <br /> MEASUREMENT ,l <br /> r FE y ) <br /> i} iJ PERMIT <br /> 'a %f�i+'+f"' ,".$4,k", r N,. �> <br /> REQU[.REMEIVTt° „ <br /> ` r r' f„5, .w.' y;,,� y ''�ic,',•,r /,� r' - ✓+i°, <br /> �N ^L(UNDUI i C-r, SAMPLE <br /> I -ik U TRt A 1 ME'N 1► P L lz 1 MEASUREMENT <br /> '�G !Sp` REGPERMITUkRL�MENT i ;t'St °1b f'�1,". 8 " <br /> LIJ <br /> S':L 10 S -T 64 L SAMPLE . zit ;�%/: � � ^t -01=,L v i>*R: \� <br /> LfIJSOLVED EM /f f MEASUREMENT <br /> t l)2 95 V 1.'G4 r \ V4 L J P8RM1't �Sig�fr4 4.41 tu'aK*..i44ril +�. ':_ ' wz`., ' � '-;�� '* ��,�„3, s:�" Jd�x' ,r ';'� �' :;�,;,��'� , �z C�:•;;;i% <br /> A REQUIREMENT fr, qy' n/, it/,'• " ' <br /> ,. N0, <br /> yr,, <br /> L.'.r►,1.,' AA- U. GREAS SAMPLE ti' ;" fX 1i'=i%i•7f%•- r-'�.%•.: x \ :" %r <br /> -aMEASUREMENT g <br /> .L - PERMIT �L Ll't ';.i ' ° I „�;�:Y <br /> g4 TR , REQVIREMEN7 / Jnx R. a, >r. n'a�,, 6 ;s <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T EY <br /> AND AM PAMILI AR WITH THE INFORMATION SUEMITTED HEREIN AND ■APED <br /> ON MY INQUIRY OF THOSE INDIVIDVAL• IMMEDIATELY MRSPON/IELE FOR ° <br /> DETAINING THE INFORMATION, I ■KLISVE THE BUEMITTED INFORMATION <br /> 1/ TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE BIG- ` <br /> f(}'•� NIFICANT PENALTIES FOR SUSMITTING FALSE INFORMATION, INCLUDING `�.F�'r'• �~ (�' 1'~ () <br /> t THE ►OBB IEILITY OF FINE AND IMPRISONMENT. ■EE 1/ V.B.C. § 1/01 ANo <br /> - /U >'a u.B.e. § ,au. penalties under these statutes may SIGNATURE OF PRINCIPAL EXECUTIVE y\ "y 11. .'�'a -j/ �K��-r t -� <br /> ( y include fines up to$10,000 <br /> .TYPED OR PRJ INTED and or maximum imprisonmentof between 6months ands ears. OFFICER OR AUTHORIZED AGENT AREA <br /> years.) CODE NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />.. 1- -01 L11I. CHAkGi tL l l.�r,(� :i,T 9°;s _ i ..:'i : ,r t .. i 1 LL. 11 �a <br /> a ..- t 5 Ii}"l��„7.. i�L' 1���.(1..:� K � t.> f :.J - lei. ♦ ♦ i.'', 1. .- HNItr l (:zl. <br /> EPA Form'3320-1-(Rev.10-79)I,PREvrous EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> UNTIL SUPPLY IS EXHAUSTED. <br />