Laserfiche WebLink
LACSD USE ONLY SANITATION DISTRICTS OF LOS ANGELES COUNTY I i <br /> Imes F.Stahl,Chief Engineer&General Manager <br /> )r information,please call(562)699-7411 ext.2900 <br /> LAB REPORT SIGNATURE PERMIT NO. <br /> Y❑ N❑ Y❑ N❑ INDUSTRIAL WASTEWATER <br /> DATE RECEIVED INITIALS SELF MONITORING REPORT SURCHARGE ACCOUN• <br /> Report due no later than 03/25/2006 <br /> 1.Name of Company Having Wastewater Discharge 2.Has the Ownership or Ocncy Changed Since the Last Report? <br /> irim:. f r� -juRi .,.L ❑ Yes ❑ No <br /> 3.Address of Wastewater Discharge 4.Name of Industrial Wastewater Contact 5.Phone No. <br /> i.•N,!L t!i l c"...Vu V L- 'v <br /> 1. i.J 11 y ../•+ 7 f,S. -� 3 ` t:h I <br /> a . t-rt,;,`•r .J C 4.;i ( .5::. ). ,. ,7 '' <br /> 6.Mailing Address(If Different from Above) 7.Sic No.(a) 8.Reporting Period <br /> . `trsv , i,-41 i,- i c.L' iiu 'rc_ yy'�31 .k -,j From:02/tIlteudor&2/2 <br /> 9.(Print)Name of Company Collecting Wastewater Sample 10.(Print)Sample Date 11.(Print)Sample Location(s) <br /> c J.c;i--ed Lca b o r a Lc,r i e s -i 2; — 2/10 ;,cn <br /> 12.Daily Wastewater Discharge For Reporting Period(Gal.) 13.Method tor Determining Wastewater Flow For Sampling Day(Z01.Z02) 14.Type of Composit! <br /> Average: �I 5 I&Direct Measurement ❑ Time Composite <br /> Maximum: (.^ 50 ❑ Adjustetl Metered Water Supply Flow Proportionec <br /> ❑ No Dis rge'During Reporting Period <br /> 15.NOTE: <br /> a <br /> 1 ' <br /> t <br /> t <br /> CODE PARAMETER (1) SAMPLING METHOD TEST RESULTS (2) LAB ID <br /> _ <br /> C, <br /> � <br /> �J i":.i•1 ' �. Cx <br /> 0 V•C; <br /> ;}.C) c) <br /> L'f iL�.r<:JLj ff VL V1!4VL in l.'V L l-"r'•L.' <br /> �1-•.v;i L: \iJ tJ r / i•! r �� 1 <br /> L I• C it r sJ ' •�n.-i 7 =(,i. �.% <br /> tt .t rtL .moi �rivr' It tiJ� `L ar<; //< 7l^,0 <br /> L 7 r(.I:Lt,.i i'-. ,C 1 III,' - li UL`/ L. J::K-_ \ ( `./. <br /> i�•! AP, L/ cul. i1 Z. Q' o 55— <br /> IT <br /> 7 Laivi` i i 1:L k i L <br /> r r t-i,r V i I\/L \V v1 i. '11 V �.•a`-•• <br /> 1 <br /> i•V f <I W.L. 1 '''11J/ v�rj itr 1_1 T': /� <br /> I r,L l '';l,l.� i� J.•9r';, sl L C�.D(_� <br /> ,SC <br /> 1�c ♦:.� _.� <br /> 'i,o4, i 'Iv/ L) � L ;'r'.1 17i CC)-oo <br /> k' M.j/L; '..Li ir';:,i1i G . <br /> � i ...V a•_;i ..� lily/ L ) ,. _:'i t":.;`,jT -._ (1 - <br /> (1) Report the test results from the most recent sample collected within the reporting period and include all laboratory test sheets vOth the self-monitoring report form. <br /> (2) Test results are valid only if the correct sampling method is observed and the laboratory analysis is performeb 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 person <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 infor <br /> information submitted is,to the best of my knowledge andtMef�true,accurate,and complete.I am aware that there are significant penalties for submitting false information,including th, <br /> of fine and imprisonment for knowing violations. *Sn f <br /> / i / / ' if i; l <br /> Signature of responsible company official Date: <br /> —77 <br /> Print name ofofficial: )E 1 '``a f I�C�Y 'r - Tide: <br /> FERMITEES CVPY <br />