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PERMITTEE NAME/ADDRESS pns,d. F.:mry Na./lana l/Dt~ssrJ <br />NAME :i :i h'.. 1. Z: ;-U.~I. ~, .:Mf S'.v <br />ADDRESS U +~ A ~« :, H C. <br />:iAYl1iM1 CU 91u3'a <br />FACnrrv <br />LOCATON .IAi /:h (;v /jlb 3~) <br />eL':::: ., ..UL' f+r•%'.4, ce::I+AL AhAGE9 <br />NATIONAL POLLUTMT DISCHMGE ELIMINATION SYSTEM INPDESI <br />DISCHARGE MONITORING REPORT IOMRI <br />7-161 17.19/ <br />,;OJOI'.i[i ' <br />PERMIT NUMBER DISCNMGENUMBEA <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM ~ TO ~ r% t <br />1767Ef l71-131 !1415/ (1677) l78-791 /363!1 <br />Form Approved. <br />- : t.., . ~ -~ ....- ._~ .OMB No;J2046000~ <br />~Approva eXpl ee-05.31-98 <br />(-vIF~ ~.) 4.-.SI T ~ <br />- FI!~! <br />rlgcF <br />NOTE: Rsad inatruedons belwe eomplatinp thu form. <br />PARAMETER 13 Grd On/p QUANTITY OR LOADIF,Ify , l~ Grd Onhl QUANTITY OR CONCENTRATION <br />' NO. FgEOUENCV SAMPLE <br /> 14653) /56-61/ 15b61/ <br />I38J51 14653 &c EX TYPE <br />137-371 MKY95 <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !sa-FSl /545s1 /6&)Ol <br />.,c t. (-. _,. /> DkT SAMPLE '; .;: ~::~:;::•: yr/,p :k :t-t r.; <br />t .'.'"' .. ,`r•, ,;: ( ~.~) <br />C c a L I•. F.:.~ L A i d b: A MEASUREMENT '" <br />?L;r~c, i U (1 PERMIT u%~Xr4tru <br />.... <br />~.. ;:;'I .,,t"~': <br />.... <br />..... ,c~._ <br />:, C L (. V M :S .. FITS F° i. U q REQUIREMENT :;: -yw4 9.~{i~ Y R L IJ F <br />;.rFrFC'1 -iCAT,?t 7;IA'! SAMPLE .`~~y^:a .. ,:: 4:}'~r. :;: r~:r.::; ( i3) <br /> <br />::ilr.rI;~:.:'i:ALi•:`~. <br />MEASUREMENT <br />-~ - --- <br />Tt; !•~~~-a- :i PERMIT .;: r-. Krt ~r ,-.. ~::# .. 3 ac~av~ ., r:~w:: ,;: _ ITttl Y ;;ap <br />~t CU`.:;~+T° ... REQUIREMENT +;>.: C: M4 YRT_GF <br /> SAMPLE <br />~('~ I/`'rJ~L~' lUO M SUREMENT <br />t~ (.-, <br />~~ <br />~ ERMIT <br />REO IREMENT <br />V t~ ~ ,~ V <br /> <br />~Uu'v <br />~'~ 5 MPLE <br /> <br />MEA~IREMENT <br /> RMIT <br /> RE UIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF lAW THAT I NAVE PEASONALLV EXAMI <br />AM F <br />M WIT <br />NFORM <br />SUBM <br />TTED HEREIN <br />T <br />T <br />MD B NED MD <br />ASED ON + <br />! TELEPHONE DATE <br /> ; <br />AMILI <br />H <br />HE I <br />A <br />ION <br />I ~ <br />' <br />~~ <br />-JO'+ .!~ ~ ~ CM G) MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />y <br />- <br />, TRUE. ACCUMTE MD COM0.ETE. I AM AWME THAT THERE ME <br />9GNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING .~. `~ ~ C . <br /> <br />1 <br />{ <br />j <br />I <br />~ <br />, <br />V <br />76 r ~ <br />- <br />D;r <br />' V l/D <br />V l THE POBSIBNTY OF NNE MD IMPNSONMFNT. SEE to U.S.C. 1 t00t MD ]3 <br /> <br />TYPEDIOR PRINTED u.s.c. E t sta. //r,.wA uw eMr mlver. nrr IxA,w Rn.• w ro +ro.oaD <br />.ndwmvinun lnpr'onwnr eFerww,emanelF rM6LrrA.1 BIONATURE OF %11NCIP EXECUTIVE <br />OFFlCER OR AUTFIO ED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMON IS ANV [XYLANA IIUN Vh ANT VIOLA IIVNS IHHB/enCe a//IfreMmenlS neie/ <br />EPA Fwm 3320-1 IOS-95) Previous editions mey be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.) C 0 C ~ s / 9 7 ] G 31-151 3 PAGE lOF <br />