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PERMITTEE NAME/ADDRESS (1~4. Fxtl.y Naw/LocnIm llD~i.F.p
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<br />NATIONDISCLNARGEDMONITORING REPORT lOMR1PDES1
<br />1-781 I7-191
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM ~i a ,~I 1 TO •" "" "'
<br />II4IIl !TT-T3/ !1475/ !7677/ 1T8-791 !3437/
<br />Form Approved.
<br />-•-- ~ •. • - ~ ~ ~ T:. OMB~No.~2040-0004..
<br />(- „ 1 Approval ezPires 05-31-98
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<br />NOTE: Reed instructions before complatinQ this form.
<br />PARAMETER !3 Grd OnlYl QUANTITY OR LOADING !~ Grd Onlvl QUANTITY OR CONCENTRATION N0. FREQUENCY SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 16T-8l1 !84681 !8&701
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<br />NAMEITITLE PRINCIPAL EXECUTNE OFFICER I CERTI
<br />AM FA FY UNDER PENALTY OF
<br />MILIAR WITH THE INFO LAW TNAT 1 HAVE PE0.50NULY EI(AMINED AND
<br />RMATION SUBMITTED HEREIN; AND BASED ON
<br />///~~~ TELEPHONE DATE
<br /> MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR 111
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<br />h OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS
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<br />AMT PENAL71E5 FOR StreMITTiNO FALSE INFORMATION
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<br />THEPOSSIBNTYOFRNEANDIMPgI50NMENT.5EE18U.S.C.f1001AN0]]
<br />SIGNATURE OF PRINCIPAL EXECUTNE ~){, 9a~-~]~~ 5 J1 D?
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<br />COMMENTS AND EXPLANATION OF ANY vIDLA I IVNS Irlerersncs s/r ertecnmenrs nets/
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<br />EPA Form 3320-1 108-951 Previous editions may be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.1 ~ ,_ ..,, t I _• , , _~ ~_ , ,~ , PAGE , OF
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