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PERMITTEE NAME/ADORE65 pr Lb fxrkry Na/lecanon UD~q
<br />NAME ~ `' ; i = e .., ~ r - _ -
<br />ADDRESSC'Ipr;:_..~ 1E'`c.l :Crr-~r .'' :1~ ~r '~
<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTANT DIBCNAAGE ELIMINATION SYSTEM (NPDESI
<br />DISCNARGE MONITORING REPORT IOMR)
<br />l1-76I lI7-191
<br />'.:7177111; n.11 r
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM + TO
<br />!10.111 172-131 124151 116-171 128-191 !36311
<br />Form Approved.
<br />- ~ • -~ ~ OM&No: 2040-0004••
<br />f- ... .. ~ ~ i ~ Approve! axpi{ee 06-31-9B
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<br />NOTE: Read instructlorrs before complatina this form.
<br />PARAMETER l3 Ord OnlPl QUANTITY OR LOADING /i Grd Onlvl QUANTITY OR CONCENTRATION NQ FREQUENCY SAMPLE
<br />31 (06-531 154611 !38451 !46531 15J-611 DF
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<br />UNITS EX
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<br />161-6]1
<br />ANALYSTS
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<br />646~1 TYPE
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<br />169-701
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF uW TNAT I HAVE PERSONALLY EXAMINED AND
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN
<br />AND BASED ON
<br />~ TELEPHONE DATE
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<br />MY INQUIRY OF THOSE IHDIVIDUAlS IMMEDIATELY RESPONSIBLE FOR
<br />OBTNNING THE INFORMATON, I BFLEVE THE SUBMITTED INFORMATION IS /
<br />1,
<br />
<br />~
<br />Richard Mills TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE
<br />SIGNIFICANT PENALTIES FOP SUBMITTING FALSE INFORMATION
<br />INCLUDING ~,~~~/ r
<br />~
<br />[:IVironmental ~:;anager .
<br />THEPOSSIeILITYOFFINEANDIMPRISONMENT.SEE1sU.S.C.Il001AND3] f970 87D-271 8 21 9
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<br />ED OR PR .lq wmuinr.n Mwivnrnt of Newwn slrlwrdra rN6r.va/ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV
<br />GVMMCrvID XIVU CAfLAIYMIIVIY VP grRT YIVLMIIVIYJ r/TBle/IOCe a//IrreCOTIOIS Oe/i/ -
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<br />EPA Form 3320-1 108-961 Previous editions may be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) r n ~,t ; 7 n o ~,J „.7 _ 1 ~ ~ 1, PAGE ~ OF
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