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PERMITTEE NAME/ADDRESS prelude PacUlo,Now-4oaorlar IrDtAirnrr) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved.
<br /> NAME i DISCHARGE MONITORING REPORT(DMR) N IN-Al
<br /> OMB No.2040-0OOM1 '
<br /> ADDRESS°:H i F.L.'.,i.y' €'Fti:!�i;"•.;.r i�>,„a,t: _1w
<br /> _? .. PERMIT NUMBER DISCHARGE NUMBER i' F'1'`a.,. '`=3�t
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<br /> NOTE:Read Instructions before completing this form.
<br /> PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
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<br /> NALWJTM.E PRINCIPAL EXECUTIVE OFFICER I eerti[y under penalty of law that 06,document end all attachments were tis TELEPHONE DATE
<br /> d tmdcr cry direction or s
<br /> PreP� li uPropiriy in accordance with a inforr designed
<br /> r �+j,•+ ,'j to assure,that qualified personml properly gather and evaluate the information
<br /> submitted.Based on my inquiry of the person or Persons wbo manage the sysum,
<br /> f ,..tltpu persona directly respomible for gathering the information,tls in!nation •��.
<br /> y L ! ), submitted is,,to the best ofmynow kledge and belief,true,accurate,and complete. SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> ;
<br /> I am aware that then:are significant penalties for submihing false infomatien, OFFICER OR AUTHORIZED AGENT- A v
<br /> TYPED OR PRINTED ncluding the possibility of fine and imprisonment for knowing violafiom NUMBER YEAR NO DAY
<br /> COMMENTS AND EXPLANATION OF ANY VIOLATIONS(Reference all attachments here)
<br /> I
<br /> EPA Form 3320-1(Rev.3/B9)Previous editions may be used. :100`:`i 10",MIN'•i8 a-41—LfOTID. PAGE � OF �'
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