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a z r LACSD USE ONLY SANITATION DISTRICTS OF LOS ANGELES COUNTY Imes F.Stahl,Chief Engineer&General Manager )r information,please call(562)699-7411 ext.2900 LRB REPORT SIGNATURE PERMIT NO. Y❑ N❑ Y❑ N❑ INDUSTRIAL WASTEWATER DATE RECEIVED INITIALS SELF MONITORING REPORT SURCHARGE ACCOUNT NO. Report dNDo later than 1G/15/Ef3Ub _ . •., . : , i 1.Name of Company Having Wastewater Dischar a 2.Has the Ownership or Occupancy Changed Since the Last Report? r._ f •:.e f r r, u_ , �,�•:: +L ❑ Yes ❑ No 3.Address of Wastewater Discharge 4.Name of Industrial Wastewater Contact 5.Phone No. j... >v.w l i. 4"C s...•is a _ l� `f 11 t',• .,i 73-r•._ .J.. i g ss(If Different from Above) 7 Sic No.(s) B.Repor(�t�sin Period 7�^ + 6.Mailing Address 4.•.i. VL.h.j�L;j �l.r 7 •, t:. _. 4Y-..::f [. t.i .- FrdrTf /Q�•/2GO6,-ftlt9,13*1 <lj_ _ 9.(Print)Name of Company Collecting Wastewater Sample 10.(Print)Sample Date 11.(Print)Sample Location(s) ASSOGia--d Labor tori GS 9/4 "- 9/8 Pair halt F Luitie 12.Daily Wastewater Discharge For-Reporting Period(Gal.) 13.Method For Determining Wastewater Flow For Sampling Day(Z01,Z02) 14.Type of Composite Sample i Average: I + CLQ Direct Measurement ❑ Time Composite --� Maximum: � rn�� r �`�� ) ❑ Adjusted Metered Water Supply Al Flow Proportioned Composite I ❑ No Discharge During Reporting Period i 15.NOTE: i CODE PARAMETER(1) SAMPLING METHOD TEST TTryRESULTS (2) LAB ID CODE(3) r,n 1 �ni ZLti r :1 a :r a a 1 ;j tit A t ,k,Jr _iriuca. oULI,.; (P"v/L) LtrAitir✓L lN+4J/L) 1tir7Ha .L:� ti!v/iJ Ltri'iIr";1:.a1 0�., irj' .-r.. {•v s.ra t• tr L h,< :...►, is •.+h.i::.H:7 C ""iJ/L,i v tS N r, C., . -} I .i � ♦" vavlje.:..t. Ni.. TUU/L1 (Cl Cl ..V 7 Li.i L JCi 't Y L :aC. L•J t.f/L) Vit6:tJ t a.C ) r I L •\M+..!"iL u1�LG I ;f (�.y:.i. UW L v .)tl+fa,r t LUk,j L j at:ML ! , . .,iti;,.,'fl:t-Jt1i•. lJVfrs_J i�t1}iZr ( G I LI�V.I:/.L/JL1•it V.{1L •�iJ(II LJ Vr'.H L: . ic. o L.Y+ : tit"lilt; rli« ;U1•/ice) KA 4 i L ..+_.riLL•r,vt.civi: •at 1 WIV L/ r;r:- r- i L,L" L) L4 0,, Q ' - ..• il.yi_�.i'�vi,ii/LCtf i:lU'J/L1 `�r::�:: ��'• (1) Report the test results from the most recent sample collected within the reporting period and include all laboratory test sheets with the self-monitoring report form. (2) Test results are valid only if the correct sampling method is observed and the laboratory analysis is performed by a State or Sanitation Districts'approved laboratory. (3) Indicate the appropriate laboratory certification I.D.Code for each testing parameter. CERTIFICATION BY PERMITTEE I certify under penalty of law that this document and all attachments were prepared under my direction or supervision In accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on. y inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,the j information submitted is,to the best of my knowledge and e(ief,true,accurate,and complete.I am aware that there are significant penalties for submitting false information,including the possibility I of fine and imprisonment for knowing violations. / i Signature of responsible company official: A/V )�' Date: Print name of official: Title. PERMITEES COPY