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PERMITTEE NAME/ADDRESS pneLdrFacility NorWLocotionjjDs•8;nenr)
<br />NAME
<br />ADDRESS C A it b y 1t J U N T 1 ! S !! t 'N t.
<br />27d SA4YEP, D'o!VE
<br />,)URANG) 23 '31.331
<br />FACILITY i{ i C J 4 C. iI L (. J (•
<br />LOCATION
<br />47'1'nI kin 1. t'h'1'1'1zNF" r, Q 7';T11FE'T
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARC NITORING REPORT (DMR)
<br />2-16 _ 17491
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM q -)10 't I TO (; r,l 1< .j 1
<br />(20.21) 122-23) 124.25/ 12627/ r28-291 x30311
<br />Form Ap--oved.
<br />OMB N 'p-0004,
<br />Approv ires 05-31-98
<br />F - I `i
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<br />NOTE: Read instructions before Completing this form.
<br />PARAMETER
<br />(3 Gid Only) QUANTITY OR LOADING
<br />(4 Card Only) QUANTITY OR CONCENTRATION
<br />NO.
<br />FREQUENCY
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<br />146531 15481/
<br />138-45) 14653 (54-811
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<br />OF
<br />I32-371
<br />EX
<br />AI'I
<br />/'TYPE
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<br />MAXIMUM
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<br />16Z-631
<br />!64 681.
<br />(69-701
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<br />NAMEfrITLE PRINCIPAL EXECUTIVE OFFICER
<br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON
<br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />r�
<br />TELEPHONE
<br />DATE
<br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE, ACCURATE • AND COMPLETE. I AM AWARE THAT THERE ARE
<br />s
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. S 1001 AND 33 /
<br />U.S-C. S 1318. 1PetwA*s under rheas sbtubs may kIchtde rows up to $ 10,000
<br />endamexmunlmptson~to/atwoon6monthsand5yeam)
<br />SIGNATURE OF PRIN PAL EXECUTNE�I
<br />OFFICER ORAUTHORIZED AGENT
<br />TYPED OR PRINTED
<br />AREA
<br />CODE NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />1.UMMICI111.7 AIVV CArLF1I4A I IVIY Vr P%NT VIVLAIIVFW0 Irxara/anCe all alracnMen(S neral
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<br />EPA'Forrn 3320-1108-951 'Previous'edltion9 may be used.'-
<br />(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
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