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LACSD USE ONLY SANITATION DISTRICTS OF LOS ANGELES COUNTY ! tines F.Stahl,Chief Engineer&General Manager it information,please call(562)699-7411 ext.2900 ! LAB REPORT SIGNATURE PERMIT NO. Y❑ N❑ Y❑ N❑ INDUSTRIAL WASTEWATER DATE RECEIVED INITIALS SELF MONITORING REPORT SURCHARGE ACCOUNT NO. Report due no later than 03/15/2006 - 1.Name of Company Having Wastewater Discharge 2.Has the Ownership or Occ*ancy Changed Since the Last Report? ❑ Yes ❑ No 3.Address of Wastewater Discharge 4.Name of Industrial Wastewater Contact 5.Phone No. .L.. . v r.r.• L t:: l 1..i Y[.t';va •fr :. Y i. G 3 :ir • •i L,tf:•i t', .! 6.Mailing Address(If Different from Above) 7.Sic No.(s) 8.Reporting Period .aiI - it-_L L v _r,;. ': LA y,;�.. YI- ,., From P21/011200-,ToC2/26/26! 9.(Print)Name of Company Collecting Wastewater Sample 10.(Print)Sample Date 11.(Print)Sample Location(s) Asp_-c>ciated Laboratories ' 2/6 - 2 '1.0 PaacShal..l 12.Daily Wastewater Discharge For Reporting Period(Gal.) 13.Method tor'oetermINng Wastewater Flow For Sampling Day(ZO1,Z02) 14.Type of Composite Sample Average: r + ` Direct Measurementtt❑��TT�ime Composite Maximum: ❑ Adjusted Metered Water Supply 'ET-Flow Proportioned Composite I ❑ No Distarge During Reporting Period I i 15.NOTE: # Y I Mimi f � ! I i i CODE PARAMETER (1) SAMPLING METHOD TEST RESULTS (2) LAB ID CODE (3)! �. L war L1t JC_ Jt-L Zu V V LS.,iv�i J.l ( r. 1 C",C. � L�CLL .3CL i ti+:� Li vi .A6 �� i vi"Au ✓� �:J . i is1VLLi'.L 1-11i.:ir, 17C,,i, 4 t' �.l.,('.• .."�i' i.i�• .! t.t rS.+a /( :. I rt i+.si L':f L. 1 %'A;it IJP ;J Imo+. l-' t : • =511r't �L� +Nl :lititl�" 1.. L .71ZK.i i0. 0 I a 1L(1Lt, t-c.. i.. iD r.+1 i': k%•`. Lt it 'i- +.. . i ii".r'1.:iL,..tivi � r1YLLie:_ Uu L '�s{tiU t• G�'Q c Ho w�+:.iL rlLu-:L•i'i1 �r9ii ,L v•' L Jr\riL l (. ) L Lrr4.A. f t V•• C'r'y} L r.V1' km'j L J :.Y r( vLL L+�+L Juj i A.: 1�. Jit.li l--.\1:.r Z.+e r_:,1, �:v L •Jho^ a�'U�1•L✓' + 1.L i i-L r*U.:L."4 9- v,3 L ,.3'- �14hL V!', C 1, L.% :J!;yiU 0.O D! I V a.•.: Ll..l�a_�.tt�:i- is+..,s;. �,UV L) V^.ML i.•/ (1) Report the test results from the most recent sample collected within the reporting period and include all laboratory test sheets vJlth 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. i I (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 my Inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information. the I information submitted is,to the best of my knowledge and ba!(i f,true,accurate,and complete.I am aware that there are significant penalties for submitting false information,including the possibility ; of fine and imprisonment for knowing violations. /.7 I i :31" Signature of responsible company offigial:� f• Date: { ! t i••, Print name of official: t r':'r `-�` "r 1t C Title: i PERN11 T EES COPY