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<br />NATIONAL POLLUTMT DISOHMOE ELIMINATION SYSTEM (NPOESI FONrI ApPfoYed.
<br />DISCHARGE MONITORING REPORT IDMRI _ ~ pMB No. 2040.0004
<br />l1-J5l 117-191 .. '
<br />_ ~ I . ., Approval expirse OS-31-98
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<br />PERMIT NUMBER DISLHMGE NUMBER ~ _ ~~- r
<br />MONITORING PERIOD '
<br />YEAR MO DAY YEAR MO DAY __
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<br />l1PI1l /11-Z31 /1d-151 116771 125-19/ !3(131/ NOTE: RHd IMwctlorte before corripletlnp thA form.
<br />PARAMETER !3 Grd On/yl QUANTITY OR LOADING f! Grd Only/ QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE
<br /> 146531 l5b5/1 I3Br5 146-531 15b6J/ DF
<br />137-371 EX
<br />MALY515 TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rt7d]1 16d-6q1 !5&70l
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<br />NAME(TITLE PRINdPAI EXECUTNE OFFICER 1 CERTI FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND 1 TELEPHONE DATE
<br /> AM FA MILIM WITH THE INFORMATION SUBMITTED HEIIEIN: AND BASED ON
<br />.~ MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR /
<br />~~ ~ }~` ~ I f 'i~ `.y~ OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS ~
<br /> TRUE. ACCURATE MD COMPLETE. I AM AWME THAT THERE ME
<br />SIGNIRCMT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING ~ /~ `
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<br />11' .. < . T ,
<br />THE POSSIBILITY OF RNE AND IMPRISONMFNT. SEE 1B Us.c. f 1001 MD 77 ~
<br />SIGNATURE OF PRINCIPAL EXECUTNE ~ ~
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<br />OFFICER OR AIRNORRED AGENT
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Relrrence a//ettschments here/
<br />EPA' Foiril 120-T 108-961 PrsJloue adilione mey be utdd. ~ ' ~ ' ' ~ iRETI:ACEB EPA FORM T-40 WRICH MAY NOT~BE USED:) ~ ~ %, ! - _ PAGE , OF
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