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PERMITTEE NAME/ADDRESS lln.l~de Fuailin Nome/l.u, nu„u /D,J/ercnq
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<br />LOCATION L ` ^ 7 ~ ~ ~' ~ `.~ ~(j ~, I ;
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<br />NATIONAL POLLUTANi~SCHARGE'EUMINATION SYSTEM (NPDES)
<br />DISCHARC 7NITORING REPORT (OMR;
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<br />, ~ r; :.~ ~ 1 PERMIT NUMBER DISCNAnOE NUMBER
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<br />YEAR MO DAY YEAR MO DAY
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<br />Form App[DVed.
<br />OMB No 7-0004
<br />"1 ~.'- h Approves .res 0531-98 ,
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<br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF l
<br />AM FAMIIJAR WRH THE INFORM AW THAT I HAVE PERSO
<br />ATION SUBMITTED RE NALLY E%AMINED ANO
<br />IN; AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDNIDUAL S IMMEDUITELV RESPON SIBLE FOR OBTAINING
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<br />i THE INFORMMTION, I BEl1EV E THE SUBMITTED IN FORMATON" I5 TRUE, "
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<br />PENALTIES FOR SUBMffTIN I AM.AWARE TRAP TH
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relarance all attachments herB) ~ ~ ~ ~ '
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<br />FPA Ferln :9320 1' (08-951 `Previous eAitions may Writ be used. ~ ~' ' (REPL'ACESe EPA FORM T=40 WFtICH'NPAY W6r BE`UsED.I` - ~ `~ " ` ~ ~ ~ ` ~~ - ` - PAGE - rir-
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