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<br />NAME ~'It .r o... ..- y -,tpr,•
<br />ADDRESS v T ', ` ~ r I' r ~ ' _ " e, !
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<br />NATIONAL POLLUTMT DISCHMOE ELIMINATION SYSTEM INPDES)
<br />DISCHARGE MONITORING REPORT !O RI
<br />J-761 l17-19I
<br />PERMIT NUMBER DISCHMOE NUMBER
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<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />. ~ r • • T r •, ^ n• ? r ¢ -TOMB No.t2040-000q
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<br />PARAMETER 13 Grd Onlyl QUANTITY OR LOADING !4 Grd Onlyl QUANTITY OR CONCENTRATION ND FREOUFNCY SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS leasal !64691 169-701
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<br />NAME/TRLE PRINCIPAL EXECUTNE OFFICER I CERTI
<br />AM FA FY UNDER PENALTY OF
<br />MILIM WITH THE INFO LAW THAT I HAVE PERSONALLY EXAMINED MD
<br />RMATION SUBMITTED HEREIN; MD BARED ON TELEPHONE DATE
<br /> MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR ~_ ~ r
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<br />2lchard ~~~~~$ OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br /> THE POSSIBILITY OF RNE MDIMPaSONMENT. SEE to U.S.C. 11001 MD3a
<br />SIGNATURE OF PRINdPAL EXECUfNE 7n _7
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