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PERMITTEE NAME/ADDRESS(/ i,J. FmWyNar/Loe.naw UOlpr.nu)
<br />NAME PU'rUhHK!)n'r CVeL _J'sP3kY
<br />ADDRESS k J A~ E~ T_ U i. ~• I .~ L ., :. ., i J P. T A L S
<br />P.U. ~ :/ ,I15,
<br />PA Li ;P.~,. U:i _x`_'20
<br />FACILITY
<br />LOCATION
<br />NATIONAL POeLUTARiOIS01(IVIGE EGMMA776N3YaifM /NPOfSJ
<br />DISCHARGE MONITORING REPORT IOMR!
<br />7-161 17-191
<br />C~ 2714 7 A
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM Y / +i4 :i 1 TO "i C : ~+
<br />IJO.J II IJJ-J.?1 tlb751 /J6Dl 1J9-791 /3Q311
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<br />NOTE: Reed Imtruetions before co tiny this form.
<br />PARAMETER !3 Grd Onlvl QUANTITY Oq LOADING II Grd On/Yl QUANTITY OR CONCENTRATION NG FREQUENCY SAMPLE
<br /> !06531 Sae/1 lie-<51 !4653 !54611
<br />EX OF
<br />TYPE
<br />l37-371 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS /e7-sal MALyas
<br />IW.eBI 1e9-701
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<br /> MEASUREMENT ~~ l'SGI'-Ff Z ~,~
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<br />~'J :i 1' E r U ~ u MEASUREMENT
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<br /> MEASUREMENT '
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<br />(AS z';;) MEASUREMENT
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<br />:'J J-11i 1 (, v PERMIT is ': i'C7 ~t T` F: F:PL~F;T Ki 91aaGA a:lGfi4L rtfier7n>? + t+r,:'+ tP:KL~• H:~".+:
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<br />NAME/TITLE PRINCIPAL EXECl1TNE OFFICER I CERTI
<br />AM FA FY UNDER PENALTY OF LAW THAT I HAVE PER90NALLY ExAMINEO MD ~
<br />MILIM WITH THE INFORMATION 9UBMIRED HEREIN; MD BASED ON ' TELEPHONE DATE
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<br />MY INQUIRY OF TNO9E INDIVIDUAL9 IMMEDIATELY RESPON9BLE FOR'
<br />OBTNNING THE INFORMATION, I BELIEVE THE 9UBMITTED INFORMATION 19
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<br />lJ THE P09SBILITY OF RNE MD IMPI1190NMENT. 9EE 19 U.9.C. F 1001 MD 9J g1pNATURE Of PRINGPAL EXECUfNE
<br /> U.9.C. E 101 e. /1RIrWJYJ ur,I.r dwrr Nenrlr. nlrY M,Fhd. rxws up ro J 10,000 /
<br />TYPED OR PRINYED .nA rY main..., Mpiv+IwN OI Mrwwn a,m,e,aaMby.ra.) )/ OFFICER OR AUTJIORIZED AOENT CODE NUMBER YEAR MO DAY
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<br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONS lRS/erence N/ ettscAmenra Here/
<br />:+r.TiLtA~Lc SU1.IG5 LIPlt AfrLIES ONLY iF C=1J'ir,/].~I;E P3tCIl'ITA7LCH FYPAT Iti CI,1•IPEL. FtFMI'.7~t' :i65
<br />c.UhLRN OF PRUUF ..".EA rc,~vrS:INL+ „!.LIEF F'A'J'! :;ETTLF.FcL`' v^LIDS PF.I:".AEY LI,°:T.AT.IOb~.
<br />EPA Farm 3320.1 108-951 Previous aditiona mey be used. IREPLACE6 EPA FORM T40 WHICH MAY NOT BE USED.) G r 4 7 7 / ? 9 C 2 ~ 3 - 1 % 5 t PAGE i OF
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