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PERMITTEE NAME/ADDRESS (lneird&FoclLryNmw 1LoeanontjD46vnt)
<br />NAME {J }: A :. ? j r; . -� Y i :Y •
<br />ADDRESS C: r1% i{
<br />27;i ;,F,w'fF"V t)f_IVF
<br />&1)ItA;tG) C�� %t13J1
<br />FACILITY U A K :: I D .,+ r ;: ;; %, ; Y L IN �.
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM fNPDE$}
<br />DISCHARG NITORING REPORT (DMR)
<br />(2-16) 17-19)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR I MO DAY YEAR I MO DAY
<br />FROM v .a 1') (1 ] TOI ;,? 1'l •1
<br />12421) (22-23) (24-25) /26-27/ 128-29i 13x311
<br />Form Appr—ved.
<br />✓ 1 i' f, is C OMB N 0-0004
<br />Approve ires 05-31-98
<br />23 Ll
<br />NOTE: Read instructions before completing this form.
<br />PARAMETER
<br />(3 Card Onlyl QUANTITY OR LOADING
<br />/4 Card Only) QUANTITY OR CONCENTRATION
<br />NO•
<br />FREQUENCY
<br />SAMPLE
<br />(46-53) (54-61)
<br />138-45) 146-53 (54-61)
<br />EX
<br />OF
<br />(32-37)><
<br />ANALYSIS
<br />TYPE
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />(62.61)
<br />(64-661
<br />(69-70)
<br />(�
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<br />SAMPLE
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<br />NAME/TITLE 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 />TELEPHONE
<br />DATE
<br />{, ✓� f,;, r,• ,1
<br />! l''
<br />/
<br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE, ACCURATE AND • COMPLETE. 1 AM AWARE THAT THERE ARE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 1 1001 AND -33
<br />U.S.C. S 1318. (Pwmd&s wwW dwse moths mwy Meludo rmes up to 5/0,000
<br />AREA
<br />TYPED OR PRINTED
<br />mdor~~num/mprisomnontofberw"n6months wid5ywa)
<br />OFFICER OR AUTHORIZED AGENT
<br />CODE NUMBER
<br />YEAR
<br />MO
<br />I.VMMCIV 1 J ArvV CArLAr4A I IVIV Vr AIYT VIVLA I IVFMQ irwarerence as acracnmenrs nerall! 7 Y t
<br />T� p 11 1.1
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<br />EPA Form 3320=1108-95) ' Previous editions'mey be used. " ' (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
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