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<br />pERMITTEE NAME/ADDRESS pwdib FsleryNaWlaanm rJDid...M
<br />NAME C Y "' .. ... .. - - ^'~ A ~ ~
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<br />NATIONAL POLLUTANT DISCHMGE ELIMINATION SYGTEM INPDES)
<br />DISCHARGE MONITORING REPORT !O RI
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<br />Form Approved.
<br />.r. ~~ONIB,No.-.2040-0004.. ~.
<br />Approve axpiraa 06-31-98
<br />FACILITY
<br />LOCATION
<br />!1-151 lI7-191
<br />PERMIT NUMBER DISCHMOE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM '+~! r%; ~ TO ~'~ ~' 71~
<br />!762// l12-13/ !2415/ /?677/ !?8-79/ 130-3f/
<br />NOTE: Read Inetructiars before eomDletlnp this form.
<br />?A°.AA!ETER l3 Grd On/yl QUANTITY OR LOADING (4 Grd On/Yl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE
<br /> le6531 154571 !38-05 lee-~3 i5d-cii EX OF
<br />131.371 ANAivsls TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS raj-sal !54551 159-701
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<br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFO LAW TNAT I NAVE PERSONALLY E%AMINED AND
<br />RMATION SUBMITTED HEREIN; AND RASED ON TELEPHONE DATE
<br />
<br />KicharLi MfU6 MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONABLE FOR
<br />OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br />l TRUE, ACCUMTE AND COMPLETE. I AM AWARE THAT TNEIIE ME
<br />AGNlFICANi PENALTIES F011 SUBMITTINQ FALSE INFORMATION
<br />INQUDING ~ J~f~rla ;,. ~/,(/
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<br />THE POSSIBILITY OF RNE AND IMPRISONMENT
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<br />AND 9] SIGNATURE OF PRINCIPAL EXECUTNE O O-7 7 Q
<br /> U.S.C. f 131 B. I/rrWerr uqr B,rr rbNhs InrY ~~ fiver W R t 10,000
<br />TYPED tHt PRINTED rwwmuhwe erw'/ro'rrwrrt nt arwwn smonrAa rwS hr><1 OFFICER OR AUTHORREO AGENT CODE NUMBER YEAR MO DAV
<br />COMMON I, ANV EXPLANATION VY ANT VIVLAIIVNJ (/TeTBlBOCB B//BRBC/ITB/1f9 /IB/B/ '
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<br />EPA Form 3320.1 108-561 Previous editionB mey be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ n T 7 F / ~ n r C ,~ T _ T ~' , PAGE _ OF
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