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PERMITTI• E/ADDRE$$pnclude Facility Name2ocarion i/Di$erenrJ
<br />NAME •. ~ n ~ "
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOESJ Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR OMB No. 2040-0004
<br />(~-161 (n-~81 ~. t .. ~ .,
<br />Approval expires 05-31-98
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD ~ ^ ~ ' ' ^ •- •:-'t' '~ "'~ r e r o q r. v r ~
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 7 ~'1 B TO qq nr1 7~ ".'^r r: .•. .,. c., :.I :~"r I I ,.:. ,.
<br />;aztJ rzz-zaJ pazsJ (zuzrJ (ze~zsl (3astJ NOTE: Read Instructions betor leting this Corm.
<br /> (3 Card Ony) QUANTITY OR LO G (4 Celd OntyJ QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (48-53 (54-B7J 38-05 (46.53) (54-61J EX OF TYPE
<br />(32-37) AVERAGE MAXIMUM - ~•NITS MINIMUM AVERAGE MAXIMUM UNITS
<br />(a!-u~) ANALYSIS
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<br /> MEASUREMENT
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<br />.'L7., 1'' ':74DU'T SAMPLE / ^71 {::y r.¢ etr:'•~'„h h:!~krt it+:
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN
<br />AND BASED ON MY
<br />• TELEPHONE DATE
<br /> ;
<br />
<br />Richard Mills INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE,
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<br />l I ACCURATE AND COMPLETE. I AM AWARE THAT THERE ME SIGNIFlCANT
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<br />POSSIBILnY OF FINE AND IMPRISONMENT. SEE 7a U S.C. 4 1 W1 AND 33 U.S.C. SIGNATURE OF PRINCIPAL E4(ECUTIVE
<br />
<br />TYPED OR PRINTED 4 t3t9. (PoreNw untler Nose smnrtes mry inc/We lures up ro 510,000 erM a
<br />maximum rmpnsonmenf of SaMreenBmonW entl Symrs.J OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MQ
<br />DAY
<br />GOMML:N I5 ANU hJ(PLANAI ION OF ANY VIOLA I IONS (He1e2nCe all arCdCDmBntS DeIBJ
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<br />,ii: nFE :; ifAn cnr!PL" ANALYSIS PF,~1IIRF~ T.r VT^I4LF ~urrr .~ f+gST'^V rr1. r•.cm..[v .-nvrr rVr T..~m P,lr,"TCtV ;-!~^,A~
<br />EPA Form 33241 (06-95) Previous editions may not be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) PAGE OF
<br />,.,~,'..,, nq~~"./nnnul2-1523 )
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