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LACSD USE ONLY f SANITATION DISTRICTS OF LOS ANGELES COUNTY Imes F.Stahl,Chief Engineer&General Manager xinformation,please call(562)699-7411 ext.2900 LAB REPORT SIGNATURE PERMIT N0. I v❑ N❑ v❑ N❑ INDUSTRIAL WASTEWATER DATE RECEIVED INITIALS SELF MONITORING REPORT SURCHARGE ACCOUNT NO. Report due no later than -s/15/2 0 0 6 x 1.Name of Company Having Wastewater Discharge 2.Has the Ownership or Ocrancy Changed Since the Last Report? L 6 r L- r( 1,,t. ❑ Yes ❑ No i 3.Address of Wastewater Discharge 74 �Name of Industrial Wastewater Contact 5.Phone No. .• t%:t., f.�.. i�•. � i.. � .. .. �' .. , i 6.Mailing Address(If Different from Above) 7 Sic -No. 8.Reporting Period Frompz/J .140t :itot>��t��LC}'✓$i 9.(Print)Name of Company Collecting Wastewater Sample 10.(Print)Sample Date 11.(Print)Sample Location(s) r°.�;sCil ii31,'wci %%6 — 2 /1i} n ' .7, rt:...i t 1.1i;ii 12.Daily Wastewater Discharge For Reporting Period(Gal.) 13.,Method For Determining Wastewater Flow For Sampling Day(Z01,Z02) 14.Type of Composite Sample ; Average: H + t 4 _ - Direct Measurement Time Composite Maximum: S lL��'�� ElAdjusted Metered Water Supply ow Proportioned Composite ❑ No Discharge During Reporting Period t 15.NOTE: I I I i i CODE PARAMETER (1) SAMPLING METHOD TEST RESULTS(2) LAB ID CODE (3)' i I i i I (1) Report the test results from the most recent sample collected within the reporting period and include all laboratory test sheets Qllth the self-monitoring report form. I (2) Test results are valid only if the correct sampling method is observed and the laboratory analysis is perfornied by a State or Sanitation Districts'approved laboratory. I (3) Indicate the appropriate laboratory certification I.D.Code for each testing parameter. CERTIFICATION BY PERMITTEE i 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 I gather and evaluate the information submitted. Based ori my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the , information submitted is.to the best of my knowledge ar)d 011pf,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. Signature of responsible company official: l Date: Print name of official: = { `• t K �' �Y Title: t e i PERMITEES COPY '