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PERMITTEE NAME/ADORE59 d.:id Fr0lryNr/Lr,nw ljD,p,..,n)
<br />NAME ;yl' ^ ~i ) . .r . , .. ~ .. 7 , -. -
<br />ADDRESS w. ~ ': - ~ ~ ~ '
<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLUTMT DISCHMGE ELIMINATON SYSTEM /NPDESI Form Approved.
<br />DISCEiARGE MONITORING REPORT IDMRI _,, ~.„„ ,~ ON)BINo. 2040-0004
<br />I1-151 I17-191 ° _ ,. .' ~ -.~ 7
<br />C 1 ! 7 1 ~ R ~ ~ "• r - :1 °. ~, ~ ; I ApproJel sXPire6 031-98
<br />PERMIT NUMBER mscHMGE NuMeER ~~ _ ~ . ,. t ,
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<br />YEAR MO DAY YEAR MO DAV
<br />FROM O'1 nj ^1 TO ~n ~~ .T :... I-,. ~,..-~;,EL._~ ': f~':
<br />/767/1 722-231 !14151 /1627/ 776-791 136311 -~ NOTE: Read ImtructloRe befori eomplatinp Shit form.
<br />PARAMETER !3 Grd OnlYl QUANTfTY OR LOADING !4 Grd Ontyl QUANTITY OR CONCENTRATION NQ FREQUENCY SAMPLE
<br /> 106-531 154511 l38J51 146531 154611 EX GF TYPE
<br />I32-37I MALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS I9a631 !64661 769-701
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<br />NAME/i1TLE PRINCIPAL EXECUTNE OFFICER I CERTI
<br />AM FA FY UNDER PENAITT OF
<br />MILIM WITH THE INFO LAW THAT I HAVE PERSONALLY EXAMINED MD
<br />RMATION SUBMITTED HEREIN; MD BASED ON TELEPHONE DATE
<br /> MV INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />rtICFLIrCI .~IIIIs OBTNNING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE. ACCURATE MD COMPLETE. I AM AWME THAT THERE ME J
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<br />~nv;ron^IL'ntal ra_ nag~r SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING _
<br />97 ~
<br />79_ X71
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<br /> THE POSSIBILITY OF RNE MD IMPNSONMENT. SEE 18 U.S.C. f 1001 MD 39 610NATURE OF PRINCIPAL EXECUTIVE '
<br /> U.9.C. F 131 e. lPrrtl., IM.r err mnm, nI,Y NcAtl, rxra Im ro S 10,000 AREA
<br />TYPED OR PRINTED ,nermrinrn l,rriovrlwt,/bwrnemarN„M6Y.ral OFFICER OR AUTNORRED AGENT CODE NUMBER YEAR MO DAV
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRererence e6 sttscnmenfs nerel
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<br />Epp Form 3320-1 108.96) Previous editions may be used. IREPLACE6 EPA FORM T40 WNICN MAY NOT BE USED./ ~ ~ ~ / ~ j ~ 1 PAGE OF
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