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PERMIT'tEE NAME/ADDRESS (IKlude Fac1liry Name/raarion !!/Di$eren8
<br />NAME (,rc:-J.- ,•~v-•° Y ] i~~.-: v ^]n. 1. ~7un
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<br />FACILITY
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) Fonn Approved.
<br />DISCHARGE MONITORING REPORT (DMR~ OMB No. 2040-0004
<br />(z-taJ ('r' sJ ~ ~ T ^ ~ Approval e>~ires 051-96
<br />:7~Q27154 ^lo A (Snap Rvl
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<br /> (3 Card Ony) QUANTITY OR LOADING (I Card Ony) QUANTITY OR CONCENTRATION NO. FJTEOUENC SAMPLE
<br />PARAMETER 48-53 54-81 38-45 48-53) (54-61 EX OF TYPE
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<br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FAM FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND
<br />ILIAR WITH THE INFORMATON SUBMITTED HEREIN
<br />AND BASED ON MY TELEPHONE DATE
<br /> ;
<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE,
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<br />DODE
<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell etfechments here)
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<br />EPA Fonn 3320.1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ ~ ~ h 9 ~ ~ ~ ~ rt 1 ~^ 1 ~~ ? 7 PAGE T OF
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