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PERMITTEE NAME/ADDRESS (ln3,b FrWryNw/Leraum!/DI)/.nul
<br />NAME. ~vp. r T. Y -."L ~OR~.
<br />ADDRESS^ '. I !::~, ., I F _ ., ~ ~ ^ v " ~', F :' :[ .. ~ -+ ~
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<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHMGE ELIMINATON SYSTEM (NPOESI
<br />DISCHARGE MONITORING REPORT (OMRI
<br />12-I81 lI7-191
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<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM Y'1 "i' ';1 TO ': ,1 ni TT
<br />!767/1 l77-731 lI4751 !76771 l18-791 !3631)
<br />Form Approved.
<br />„ ~ ,r .. 1 ., r, y .. T ~ONIB,No..~2040-0004:. ;
<br />• ~ ~ApproJelI expire8 05-31-98
<br />.:" T..-;
<br />.NOTE: Reed Inetruetlom before eompletinp thu form.
<br />PARAMETER 13 Grd only! QUANTITY OR LOADING !4 Grd Onhl QUANTITY OR CONCENTRATION NO, rREOUENCr SAMPLE
<br /> !46531 /51-5lI !38-45 !4653 1548/1
<br />EX OF
<br />TYPE
<br />137-37I MALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rs7-es~ 184581 (88701
<br />~(/f.'•1CTIVITY SAMPLE ': {: 7,. Z,y t:Gr.. .. t...n;: ': ;- ~ 11)
<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIM WITH THE INFO uW THAT 1 RAVE PERSONILLLY EXAMINED MD
<br />RMATION SUBMITTED HEREIN; MD BASED ON TELEPHONE DATE
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<br />her/! 'I1'~~ff
<br />Ri MY INGUIRY OF THOSE INOINDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS
<br />/ - ~ %i.~
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<br />c TRUE. ACCUMTE MO COMRETE. I AM AWME THAT THERE ME
<br />SIGNINCMT PENALTIES FOR SUBMITTING FKSE INFORMATION
<br />INCLUDING ~~) ~ ~~ ~/ ~~/`
<br />environmental IIw7:'13 er , _
<br />Q D
<br />R Q
<br />27) Z
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<br />L THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 1e U.S.C. F 1001 MD 3]
<br />BIONATURE OF PIIINCIPAL EXECUTNE - gg
<br /> U.S.C. f t]ts. IPNMIrM• MWr dwr mnm• nr.r =xlw. Rr~. w ro i ro,DBO AREA
<br />TYPED OR PRINTED wnnMrtimnr Mprismrrrt o/WM1rnn emanNaW eYAra.l OFFlCER OR AUTHORIZED AGENT LODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/ersnce s!/ sttschmsnfe here/
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<br />EPA Form 3320.7 108.951 Previous editions mey be used. ^ IREPLACE6 EPA'FORM T-00 WHICH MAY NOT BE USED.I , ,~ , 1 „ / , ~ r ry 7 _) r T PAGE t~OF
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