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<br />PERMI7TEE NAME/ADDRESS (IrLdv Frdny Na•/l.oc•uen r/Ordirw0
<br />NAME - - ~ _ ... . _ .. -
<br />ADDPESS 'T'I '~. . ~-F 1`. - irJ'I' i • - ~~.. .., !=1
<br />
<br />
<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTMT OISCHMOE ELIMINATON SYSTEM (NPDE$1
<br />DISCHARGE MONITORING REPORT IDMRI
<br />11-151 (17-191
<br />_ x'727?~`! rt )I` A
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 7 t ) TO 'i, ! '
<br />!16111 /11-231 !74151 06171 l18-191 /30.311
<br />Form Approved.
<br />. - ~.~ r - ~ ^ • • ± ~, ~ ~~ .. •TOMB•No..2040-0004
<br />(.. •. -., -, y ~~ APProvel exPites 0531-98
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<br />•~ NOTE: Read instruetions baJ rs6 oolnpletiny this form.
<br />PARAMETER l3 Grd Onlyl QUANTITY Oq LOADING 11 Grd Onlp QUANTITY OR CONCENTRATION ND FREpUENCY SAMPLE
<br />131-371 !06531 (54-611 /38.151 !<653 !546/1 OF
<br /> EX uYSts
<br />M TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !sz-ssl '
<br />(54581 (58-701
<br />)IT SAMPLE ~~~.. ,.x Rr.,. ~..t~ 'a.^.r; ~:f:~- ( ~'~
<br /> MEASUREMENT
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<br />:':.d°_V: ,;E;74i IlAL;1 REQUIREMENT ..,.z:= 3+1nT A~•~ nArLT MY !G/L fl0h'"H
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<br />NAMEliITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PFNALTr DF uw THAT I NAVE PERSO
<br />AM FAMILIM WITH THE INFORMATION SUBMITTED H NAUr ExAMINED MD
<br />EREIN
<br />AND BMED ON TELEPHONE DATE
<br /> ;
<br />MY INQUIRY OF T
<br />ID
<br />
<br />i?Ici7ard Mills HOSE INDIV
<br />UALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATON IS
<br />
<br />~
<br />
<br />FnvironmentDl A9anager TRUE, ACCUMTE MD COMPLETE. I AM AWARE THAT THERE ME
<br />SIGNIFCMT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />(971] 87iti-Z7~Z
<br />~
<br />Z~
<br />9U
<br /> THE POSSIBILITY OF RNE AND IMPRISONMENT. SEE 18 U.S.C. 1 t00t MD 73 BIONATURE OF PRIN
<br />
<br />U.S.C. E tats. Ihn•le•• NMw et.Ar mtvn. nrr 41cNM• ~ a w ro f 10.000 CIPAL EXECUTIVE
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<br />TYPED OR PRINTED
<br />.eermuirxnl inpnsyrwlr ole.nr...smone'raWSF+a/
<br />OFFICER OR AUTHORIZED AGENT REA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />Epq Form 3320.7 106-961 Previous editions may be used. IREPlACE6 EPA FORM T40 WHICH Mqy NOT BE USED.) ~ t ~.T . /~ ~,I „ ~ _ ~ 9 ~ ~ PAGE r OF
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