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PERMITTEE NAME/ADDRESS pMib frr9ryNadL«anm l/D15innp <br />NAME CP.A ~?F. ft '1:~ ! .+ „~, <br />ADDRESS TkAFFC(t nI', <br />P.I. Pr?% 1 ~7 <br />C3Ai; <br />FACILITY <br />LocAnoN <br />.~lt; ~, <br /> <br />NATIONAL POLLUTANT DI9CMMOE ELIMINATON SY9TEM /NPDESI <br />DISCHARGE MONRORINO REPORT /OMRI <br />l7-15/ 17-19I <br />_00032115 C07 A <br />PERMIT NUMBER DISCNMGE MUMBEII <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM - ' U TO <br />l16I11 lZ1-731 lII-I51 /I8-I7/ 178-I9/ !3631/ <br />Form Approved. <br />r G I: C p r. ' C t 0 "~ A f4~MBQty.L~9A0-0004 <br />t,. C F t F .J) ADProvellelLCp;rae505-31-88 <br />T - FTl,4L <br />"YMCA <br />r'iII NC CISCNAfiGE ~__~ iOss <br />NOTE: Reed inetructlan be/ae eompletln0 this form. <br />PARAMETER 13 Grd Onlyl OUANTRY OR LOADING !~ Grd Onlyl QUANTITY OR CONCENTRATION NO. 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CATiY IR7r !'G/;. <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY uNDfR PENALTY of uw THAT I NAVE PERSOr+uLV ExAMINED MD <br />R+ FAMILIM WITH THE INFORMATION 9UBMITTED HEREIN; AND BASED ON <br />A ~ TELEPHONE DATE <br /> , <br />MY INQUIRY OF TN09E INpIVIDUALS IMMEDIATELY RE9PON91BLf fOR <br />I BELIEVE THE 9UBMITTED INFORMATION 19 <br />OBTNNING THE INFORMATON ~/ / ~ ~/~ /L~ <br />/i'+~ <br />.O.. <br />{~. Gordon Peters , <br />TRUE. ACCI/MTE MD COMPLETE. 1 AM AWME THAT ?HERE ME <br />INCLUDING <br />91GNIRCMT PENALTIE9 fOR 9UBMITTINO FAL9E INFORMATION T <br />7 <br />P d nets! g , <br />THE P095181LITY OF RME MD IMPNBONMENT. 9EE 10 U.B.C. E 1001 MD ]] BIONATURE OF PRINCIPAL EXECUTIVE I <br /> U.9.C. 1 1 ]t e. lhrlrl6E rOA- e5,w •NNr1E neY bl[eA11 5n.. ry m d 10.000 <br />TYPED OR PRINTED AvsnnMr:n/n `Ew.+.eEEwraMn.wn smoneu EA05ywA1 OFFICER OR AUTHOR12ED AGENT CODE NUMBER YEAR MO OAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRefrrence sll etgchments her~1 <br />i:::: 6 TOTnL S~+). LI.":1:. SILL f1: a\IV°::i, AyD iETTLEAf?Lc: s'1LIC5 I7M1^. AIFLIFD FCF <=10Yk.2uH4 F@ECIP F.YENT- <br />~Bi: BURDEN c; f' P".~OF RF,;OI.:i."EZwT~ U;/DEa 1.A.3• PF.RCI1'TEE MUD; ;AKE All AEA;GNAEIE MEASUirES TO ,Ri:GUI~i ~f: <br />Iti AGCORI)AhC: iTTu pc°~"~ ~^::r ~• DH r~TI~=: - cru T_].c mn^, rr•OITriZL{ j p a <br />EPA Fwm 3320.1 108.96) Previous editions mey bs used. (REPLACES EPA FORM T-a0 WHICH MAY NOT 8E USED.1 0 0 C 2 ~ / 9 7 ] ,~, 11-1 G Ii E PAGE IOF Z <br />