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PERM ITT LE 'ADDRL5S (Include NA110NA1 1.0I 1 1 IIAIIc.I I ' IMINA rII>N- Y',II Rt,\/' IS) Form Approved <br /> FaclhtyName/I onlfdlJferent/ DISCH E MONITORING REPORT ,10110 OMB No 2040-0004 <br /> �lA —N11(t-LLIi1LL11Y LL111 G CIA L_L L LK L G U l.' l r _ -_ (1'l 1),l _ F= - FINAL Approval expires 9-30-85 <br /> 0(JU�Lb ----- SOU-`�-1i JtCT 11 <UR=10YKk4HR <br /> PERMIT NUMBER <br /> oIs11+AN1.c NUMOCN <br /> ----------- ----- <br /> MONITORING PERIOD <br /> FACILITY YEAR I MO I DAY VCAR MO DAY <br /> LOCATION FROM 8b I Z I U 1. TO L 41 MINOR <br /> _ _ /20 // (22-23) (24-25) _(26-27) (28-79) (30-31) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> PARAMETER (46-53) (54.61) (38-45/ (46-33) (54-61) of <br /> (3L-37) -- -- EX ANALYSIS TYPE <br /> :7 s AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70) <br /> LliOV, 5—UAY SAMPLE <br /> (10 OL r . L ) MEASUREMENT <br /> 00310 1 U PERMIT ****** **�c*>,c* *** 45 O E/ G AB <br /> REQUIREMENT 0A e A V <br /> 7DA. AV <br /> PH SAMPLER* <br /> MEASUREMENT <br /> 00400 1 0 PERMIT Iv �x**IOa1c #**#ak* 5 ** *** 9.0 W EKLY AS <br /> EFFLUE1• GROSS VALUREQUIREMENT %k _ Nimum— MAXI UM SU <br /> SOLIDS, Si-1-1—LE—ABLE SAMPLE <br /> MEASUREMENT <br /> 00545 1 L PERMIT ** *�x * * *** ** REPURT 0.5 0 E/ G AS <br /> EFFLUENT GROSS V I ,,, REQUIREMENT # , <br /> OIL ANU GREASE ESL SAMPLE <br /> R�— <br /> FREON `XTGRt M <br /> AY E1 MEASUREMENT <br /> 00556 1 0 PERMIT 4c *** #***** * ** ****** REF'URT 10 W EKLYG AS <br /> REQUIREMEN * <br /> FLOW, IN CONDUIT UK SAMPLE ** * ** *** ****** <br /> THRU TREATMENT PLAN1 MEASUREMEN _ <br /> 50050 1 0 PERMIT RLFURT REPORT W EKLYI STAN <br /> EFEL ENT CKUSS VA <br /> REQUIREMENT `— T MX — <br /> SOLIDS , T OI AL SAMPLE <br /> UISSCLVEU (MG/L) MEASUREMENT <br /> 70Z95 1 0 PERMIT Ipc* i�*** IfF�RtK**1K * *#** * REPURT REPORT Q RLY G AS <br /> F-FFLUENT R REQUIREMENT --_- <br /> CUL IFURM, FECAL SAMPLE <br /> GEN r-L A L MEASUREMENT --- <br /> 74055 1 0 PERMIT U00 12000 0W.E1 G A8 <br /> FEELVENT <br /> GROSS <br /> REQUIREMENT <br /> r3QUA G 00M <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 c[ NDER .E Nw Lry or LAw rH AT I HAYS .cR wLLV TELEPHONE D A T E <br /> AND A MILIwR WITH TH[ INFORMATION fUO MITTED H QIN A"' <br /> O �{'I���� -^ ' ON vA INOUIRV OI DSE InO1YlOUA<.{ Iw MCOIATE I� REfPONfO M:T.O r\ <br /> r�Il L�.� 531 OQ IND r HEII INF OR MwT10N, 1 QELI[V[ TH[ {UB—AT IN. A-AT.ON `7J, <br /> /JL/ 1 • T A ATQ AND l'O APLQT[. 1 AM AWARH THAT T. <br /> l <br /> NT ENALII[f .On LUb MIITIND . LL[ InrU MATION INCLUDING —____ /wf)Ltl [y/ <br /> rH[IIPOffIRIL1IV O. FINE AND 'MPRISONMQNT. f[[ If U.{.C. § 1001 AND SIGNATURE OFPRINCIPALECUTIVE <br /> lPInalltcsunder these statutes may include lines upto$]0,000 <br /> TYPI-O OR PRINTED and/or nlaxunjon unpnsonment ofbetween 6 months and 5years/ OFFICER OR AUTHORIZED AGENT CODE REA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference allattachnents h(re) <br /> IF NO UIS%1'HAR'GE OCLURS KP1- 143 U1SLI-iRGE11 UN YOUR DNIR . <br /> EPA Fon 1 332U 1 (Rev. 10 79) PREVIOUS Cnil Intl TI- 111 -r D 1I7LPLA -L:EPA FORM -F-40 WHICH MAY NOT BL USED I PAGE OF <br /> UNTIL SUPPLY IS EXHAUS;F LU i✓ '577/ltc., �U e6-1 5 )7 1 <br />