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LACSID USE ONLY 7 SANITATION bISTRICTS OF LOS ANGELES COUNTY PAG t C-i ur"' 63 <br /> antes F.cAahl,Chief Engineer&General Manager <br /> or informakn.please call(562)6W7411 ext.2900 <br /> LAB REPORT SIGNATURE or <br /> NO. <br /> Y[-] N[] YE] N[] INDUSTRIAL WASTEWATER ull3b3 <br /> DATE RECEIVED INITIALS SELF MONITORING REPORT SURCHARGE ACCOUNT NO. <br /> Report d4sto later than <br /> ............... <br /> 1.Name of Company Having Wastewater Discharge 2.Has the Ownership or Occupancy Changed Since the Last Report? <br /> .)'UVTr1,ivLSF FKi.�LL. ,UkS INC I"i ❑ Yes ❑ No <br /> 3.Address of Wastewater Discharge 4.Name of Industrial WastewaterContact 5.Phone No. <br /> I <br /> xja nAituiiiii OLVU VI:kl1YU(14t CA 9(;ij 2 3 MRS KILHAkU JEAOmt Lb9-9d7o <br /> 6.Mailing Address(if Different from Above) 7 Sic No.(s) 1 8.Reporting Period <br /> O.ANUINI ot.-Vu VE14NUN CA 9('JQ23 4953t .2��46 . 06 <br /> Fro,94/01/ZQ06 Q,9/30/20t <br /> 9.(Print)Name of Company Collecting Wastewater Sample 10.(Print)Sample Date 11.(Pant)Sample Locauon(s) <br /> Associated Laboratories 9/4 - 9 8 Parshall Flume <br /> 12.Daily Wastewater Discharge For Rep rt'rng Per od(Gal.) 13,Method For Determining Wastewater Flow For Sampling Day(Z01.Z02) 14,Type of Composite Sample <br /> Avera ge: Direct Measurement C] Time Composite <br /> Maximum: E] Adjusted Metered Water Supply ;9zFlaw Proportioned Composite <br /> El No Discharge During Reporting Period <br /> 15.NOTE: <br /> milli <br /> CODE PARAMETER (1)j y <br /> SAMPLING METHOD TEST RESULTS (2) LAB ID CODE (3) <br /> GAA13 <br /> U'L'y k1,--UI-LhLUKOEThAtvt (UV" L) GRAd 10 '0 <br /> Q,.4-v. LL1'*ZtJ'-4C (UU/L) GAA b 10. Q <br /> 044. 1ULQLNt (Uu/0 i�RA o '34D,C) <br /> 04 'T L1,1YL0cNi.CNE (k:UiLj GRA6 <br /> (UG/L,) GRAB I C' C) <br /> Q1441 LAuAu'"MtTHAitE (UGILJ GRAB <br /> 0-ti LnLJAUt1r1ANL (Uta L) GRAB <br /> ti'+Q 4-Li1LURULTHYL VINYL (UGIL) GRAS 0 <br /> 4b49 Lr1ILUkLlMtTtiANE (uGIL) GRAa a40.0 <br /> 05t, 1 4-1)1 CHL ukt)PRO PANE: (UG/L) GRAB I (D.0 <br /> (UG/L) (;AAb <br /> (UG/L) 6RAla <br /> 114#4te-TIETkACHLURUETHANE (UGIL) GRAB < 10.0 <br /> I AifkatEllii-# TUTAL (MGJL) COMPOSITL— 0. pzt-1 <br /> I 4t.; LAUMIUMI TUTAL (MG/L) COMPOSITC C)- C a5 <br /> 1�"l LHIKLAILIM, TOTAL (Mia/1.) COMPOSITt < D-L I, D <br /> Tia L'�ALTI TLJAL (Mu/1L) COMPOSITE 0 , 10 <br /> Ile. LL.PeLKI TUTAL (MGIL) COMPOSITE 0 Qao................................. <br /> 7A.4 LL�UI 'TUTAL (MUILJ COMPOSITL <br /> lid lf`,Lr%'�tjKlfy TUTAL (t 6/11-) CUMPUSITE < (D 1 <br /> 1AC- N-0-i%r-Ly TUTAL kMoll-) COMPOSITE I I I <br /> I4-t :,ILVt.,Klf fta;TAL (Mu/L) COMPOSITL <br /> ili,,L, fU[AL (Mk,/t.) "OMPOSITE 0 . 10 <br /> TiNy I'tiTAL (Mk,/L) LL;I`4i"0SITE- <br /> (1) Report the lost results from the most recent sample collected within the reporting period and include all laboratory test sheets with the sell-monitoting report form, <br /> (2) Test results are valid only 4 the correct sampling method is observed and the laboratory analysis is performed by a State or Sanitation Districts'approved laboratory. <br /> (3) Indicate the appropriate laboratory certification I.D.Code for each testing pa a <br /> ramal r <br /> CERTIFICATION BY PERMITTEE <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supemsicin in accordance wnh a"am designed to assufe that quaitfied personnel promrly <br /> gather and evaluate the?nfortnation submitted Based an my inquiry of the person or persons who manage the SVVIUM. Or those persons directly responsible for gathering the inlormaitiGn, the <br /> information submitted Is,to the best of my knowledge i&iqh`fiaf,true,accurate,and complete.I am aware that there are significant penalties for submitting false tnlofmaWn,including the Possibility <br /> of fine and imprisonment for knowng violations. <br /> Signature of responsible company ciffici.P <br /> Daft,, <br /> Print name of ciffisciat— Title: <br /> PERNIITEES COPY <br />