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PERMITTEE NAME/ADDRESS (l.drifsnryNr/LoraNm,/DIO.nu) NATIONAL POLLUTANT DISOHMGE ELIMINATON SYSTEM (NPDESI <br />NAME DISCHARGE MONITORING REPORT (OMR1 <br /> <br />L ~ :. L S I J r <br />~ ] A L ~ ,~ '' i ~' i . • % . <br />I is , • <br />Z-161 , <br />17-191 <br />ADDRESS ,' A 5 13 I ;) i . ." I Y :' '• '" • ,. n ^ ~ <br /> P. J. N J i; / b l l ~) 7 PERNIITNUMBER DISCHMGE MUMBEfl <br /> :i d'~ e':T]N'IJ 'i% 7`•:/(t-1:%7] MONITORING PERIOD <br />FACILITY <br />t.1 :; :.iIJ'i <br />~)~L 1"~.'4`,:~ <br />1.'+.. <br />YEAR <br />MO DAV <br />YEAR <br />MO <br />DAV <br />LOCATION tI i L I „;) - <br />ul[.]~ <br />FROM <br />TI <br />I(I )1 <br />TO <br />4 <br />~, r' I. ., u: ,. r 1 " .. 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C+it { fJU' .:: lr:+: <br />~ ~l-fi {(t , s . <br />r~ ~~ `-f~ ~'~ <br />Y 1 ~ A L <br />}~ MEASUREMENT I ~ <br /> PERMIT: " RftPJfsf F.'i=1 ?SkdGGCc .a:,t~ <br />~~' •+*#??tYL=. I,•'s <br />C% <br />1"tCF/ <br />IT:; i:ll <br />r.°i (1 =:n P ~I ra ~'~ ~ J Ilc REQUIREMENT - a R tr_r C::Y :}h M' 4 4 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' `1 <br />\V <br /> REQUIREMENT ~ ~ ~Cj` <br />G <br />NAME/TRIE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF L <br />AM FAMILIAR WITH THE INFOR AW THAT I HAVE PERSONALLY EIfAMINED AND <br />MATION SUBMITTED HEREIN: AND BASED ON ^QIJ TELEPHONE DATE <br /> <br /> <br />./'! J <br />/~ ~/ <br />MY INDUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATON IS 1 <br />~~ ~ <br />r. <br />' <br />WqI! <br />'~=•E TRUE. ACCUMTE AND COMRETE. I AM AWME THAT TNERE ARE ,i 1.~y '~ <br /> <br />SIGNIFIOANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING , <br />i <br />J <br />) <br />~ , <br />THE POSSIBILITY OF FNE AND IMPNSONMENT <br />SEE 18 U <br />S <br />C <br />1 1001 AMD SJ .. \\5g ~ f <br /> <br />~• <br />~ <br />~:, ~ <br />_ <br />. <br />. <br />. <br />. <br />U <br />S <br />C <br />f 1310 <br />ln.rre <br />i <br />W <br />rh <br />bro <br />hd~~ <br />J10 <br />000 -- <br />SIGNATURE O (lXIIRCIPAL EXECUTIVE Q <br />Y Q <br /> <br />TYPED OR PRINTED . <br />. <br />. <br />. <br />n <br />.~. <br />,[ <br />r <br />n. nnY <br />•W ro <br />, <br />wsm.rinnn irw/Aawr+t el Mrww amNIIFUW SYrrt/ <br />O UTNORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAy <br /> CODE <br />li <br />GVMMCrvla nnv cnrcnnn non yr nn, vwcn nvno lne. nrencv an euacnmonrs nqe/ <br />;i :.:TL::n.iL- ~7LII'> LI"'I" h.9 Yt.J ~'):: LJ-Y! ..'4-:1 p;-+~;. ~ r -. rl .. - c - <br />I , ( L~' ::JF:, JJ.',Jul.l . i ,' '). R'.,.OIi:frE.o','f'. <br />IP,(T' T..:.1.1), ,',. v. Si'J.,".A::i? 'i4VA9c9e:tiC PL.4'~ DU'' 1-1-iu. <br />EPA Form 3320.7 108.95) Previaue editiane msy be used. /REPLACES EPA FORM TAO WHICH MAY NOT BE USED.1 PAGE OF <br />~~ <br />~_~ <br />f>.~ <br />~_ <br />~~ <br />