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PERMITTEE NAME/ADDRESS
<br />(lnrlude Fatilip•.Vame/Locmion i/D flerenQ
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) }
<br />Form Approved.
<br />NAME
<br />P I C }, E'f W I h E P Ft C C E _° S I 5 G
<br />L L C DISCHARGE MONITORING REPORT (OMR
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<br />C I h C i OMB NO. 2040.0004 r
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<br />LOCATIO
<br />~ES:CN CC FIC9I~ R MO DAY YEAR MO DAY
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<br /> (3 Cerd Only) QUANTITY OR lO- {<CeN Onty) QUANTITY OR CONCENTRATIONW NO, FREOUENC SAMPLE
<br />PARAMETER (46-53) /59-fii) (39-45J (46-53J (54-81
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<br />(32-37J AVERAGE MAXIMUM ~ MINIMUM AVERAGE MAXIMUM UNITS '
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<br />ANALYSIS
<br />(64-68)
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<br />69-70
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<br /> MEASUREMENT
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<br /> MEASUREMENT '
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNDER PENALTY O L
<br />AM FAMILIAR WITH THE INFORM AW 7HAT1 HAVE PERSO
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<br />DIVIDUALS IMMEDIATELY RESPON
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<br />I BELIEVE THE SUBMITTED INF SIBLE FOP OBTAINING
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<br />PENALTIES FOR SUBAlITTING FALSE INFORMATIO A
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<br />POSSIBILITY OF FINE AND IMPRISONMEM. SEE 18 U.S.C. 4 1001 AND 33 U S C.
<br />$jGNATURE O PRINCIPAL EXECUTIV~ 1
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<br />TYPED RPRINTED meimum~m~srnment olbgM~ee ~B meonths entl5utle lines up to St0,000 entl or
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<br />NUMBER
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<br />V V MMtN 1 J ANU tXYLANA I IUN OF ANY VIULA I TUNS (HB/B/BrICB 8// a/taChmBDIS here)
<br />;0 GAY rYEHAGt IS NIGE:.ST NChTHLY Ai6. LUFIPC PEF'ICf. Hr:FCFTEG. OIL G CSEASE - SIE I.E.I.L~ F. 5. 15i t
<br />TCiFL INCH LIMITS 4111 FE f,AIYEL, 11NC SF.TTLEAE!LE `CLIC3 LIMITS AFFIIEC ECf. <=1CYF,:4NF FFECIF FtiFE7-SE'17.
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<br />EPA Form 3320-T (118-95) Previous editions may not be used. : . ~ ~ ( EBtACES EPA FORM T-40 WHICH MAY NOT BE USED.) 0 C C 11 / G C C 1 1 7 - ~ 6 I 0 PAGE 1 OF
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