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LACSD USE ONLY SANITATION DISTRICTS OF LOS ANGELES COUNTY <br /> Imes F.Vtahl,Chief Engineer&General Manager <br /> it inform4tion,please call (562)699-7411 ext.2900 <br /> IAB REPORT SIGNATURE PERMIT NO. I <br /> Y❑ No . Y❑ N❑ ; INIJUSTRIAL WASTEWATER <br /> DATE RECEIVED INITIALS SELF MONITORING REPORT SURCHARGE ACCOUNT NO. L <br /> I <br /> Report dWe no later than =(J/ <br /> 1.Name of Company Having Wastewater Discharge 2.Has the Ownership or Occupancy Changed Since the Last Report? <br /> ❑ Yes ❑ No <br /> 3.Address of Wastewater Discharge 4.Name of Industrial Wastewater Contact 5.Phone No. <br /> l 1,. L:_ V li V L;-,f Wi 4 L:A <br /> 6.Mailing Address(if Different from Above) 7.Sic No.(s) B.Reporting Period <br /> }.Y�:.-Y t,:.:v:.;�4._,,..,♦. '7 v`;L.i. '';'. ° _. �l9�u1/2006 ?;.9/30�LGU0 ({ <br /> f- Fro <br /> 9.(Print)Name of Company Collecting Wastewater Sample 10.(Print)Sample Date 11.(Print)Sample Location(s) <br /> 0(723�.E9d L,aboral-Crl.E:S 9�4 - 9/ Parsha11 �'iu+r: ' <br /> 12.Daily Wastewaters Discharge For Reporting Period(Gal.) 13. ethod For Determining Wastewater Flow For Sampling Day(Z01,Z02) 14.Type of Composite Sample <br /> Average: , _4 2�' Direct Measurement ❑ Time Composite <br /> Maximum: y �x , ❑ Adjusted Metered Water Supply Flow Proportioned Composite <br /> ❑ No Discharge During Reporting Period <br /> 15.NOTE: <br /> 1 <br /> + <br /> i <br /> i <br /> CODE PARAMETER(1) SAMPLING METHOD TEST RESULTS (2) LAB ID CODE (31111 <br /> i _.i r? �.ri �ltL r'siiitis+L.ATC t 7 O I <br /> t�: �r,s-r;.T rt#:.�r, l•.�t.,J t. .} 1.�:,'{r's vr:r,r Ci C: I <br /> LLIMF L;IH1 <br /> Vi -vl.�.nl,,._ ♦ULJ{ L./ C. i`1 t'/ <br /> LLn;M C. LU.ii LI ir, \3!0+ - I <br /> i <br /> i <br /> I <br /> f <br /> i <br /> (1) Report the test results from the most recent sample collected within the reporting period and include all laboratory test sheets with the seff-monitoring report form. <br /> (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. <br /> (3) Indicate the appropriate laboratory certification I.D.Code for each testing parameter. <br /> CERTIFICATION BY PERMITTEE <br /> 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 j <br /> gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information. the <br /> information submitted is.to the best of my knowledge and beli ,true,accurate,and complete:I am aware that there are significant penalties for submitting false information,including the possibility ` <br /> of fine and imprisonment for knowing violations. �� / , 1 <br /> ��/� <br /> Signature of responsible company official: <br /> Date: <br /> � - - — - <br /> Print name of official: Title: <br /> FERMITEES COPY <br />