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PERMITTEE NAME/ADDRESS pnclude Faclliry NamdLocalion JDij(erenq
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<br />FACIUrY ~"
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (IJPDES)
<br />DISCHARGE MONITORING REPORT (OMR;
<br />(2-f61 (t ]- 91
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />, . ~ OMB No. 2040-0004
<br />Approval expires OS31-95
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<br />.NOTE: Read Instructions befo plating this form.
<br /> (3 Crvd Ony) QUANTITY OR LOADING (4 Card Onty) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4653) (54-81) 38-45) (4653 (54.67 EX OF TYPE
<br />(~-3n AVERAGE MAXIMUM UNRS MINIMUM AVERAGE MAXIMUM UNRS avurs/s
<br /> Isx~m) (64-68) 69-70
<br />I' d SAMPLE .. .. ., ( I o)
<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM uw THAT I HAVE PERSONALLY E7(AMINED AND
<br />ATION SUBMITTED HEREIN
<br />AND BASED ON MY TELEPHONE DATE
<br />
<br />Richard Nills
<br />INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION
<br />I BELIEV :
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INF
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<br />I AM AWARE THAT THERE ARE SIGN
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<br />PENALTIES FOR SUBMfTT1NG I
<br />FALSE INFORMATION
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<br /> POSSIBILIIV OF FINE AND IMPRISONMEM. SEE 1B U.S.C. § 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL E%ECUTNE
<br />TYPED OR PRINTED § 7310. (Penett/as under Msse statutes may Include Bnea up b ff0.000 entl or
<br />marlmum lmpdsmmer4 ol5etween emontrts end5yeers.l OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS ANO EXPLANATION OF ANY VIOLATIONS (Reference e11 etf8chmenLS here)
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<br />33261 (OS-95) Previous editions may not be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.) PAGE OF
<br />er,~i4/n~nn12-1573 1
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