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CRMITTCC NAMC/ADDRC!! (/nC)Yd! <br />Iclliry Name/LIIC[ron V diJJvenrJ <br />wMe__-__------- ....). ~ ~. <br />-/ - <br />Acsurr _ _____ <br />OCATIOM ---------------- <br />NATIONAL FO LLUTANT GIICNwgG[ [LIM IN ATION !Y!T[M (NVIJGSI <br />DISCHARGE MONITORING REPORT /D.HRI <br />I.16 l~ <br />-ERMIT NUMBER ~ oracNwwca NUM[e• <br />MONITORING PERIOD <br />YEAR MO DA YEAq MO DAV <br />FROM J J - TO 1 _ <br />170711 /17.731 /11~ 31 176- I l78~1 I ! al <br />'I Folm Approved.' <br />{.,'I;, .' ~~ ~ OMB No. 2040-0004. ~ . <br />- - f ' : !-Approval expires fi-30-91. <br />i . 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A ti <br />, <br />.. ~.i ~ <br />NAM[/TITLE PRINCIPAL E%[CUTIVE OFFICER I CERTIFY UNDER PLNLLTY.OF LAw THAT I NAVE FEP~ LLLr E%AMINEO <br />1n0 AY FAMILYR WITH TN[ INFORMATON BUBMITfED HEREIN AMD BASSO ~ ~ <br />' TlLEPNONF O A T E <br />' ~_.-...~' ON MY INOl11RY OF TNOiE rNDIVIWLLS IMMEDIATELY RESFOIGIBLC Fpl <br />/, <br />i ~ Y. / <br />I/ f"J OBTAMnaG THE INFORNAIq:E I BELIEVE TNF BUBMTfED INFORMATION <br />r ~ } <br />/' ~~~ r'! <br />' ~ <br />, <br />[~?~ <br />/ n <br />T <br />L <br />~J IS TRUC ACCURATE AHD COMRETE ,I AM AWAR[ TNAT iNEPE ARC Sq <br />' I ` 1 <br />( <br />' <br />--Y / <br />1~ _ <br />~ l / <br />NIFICANT PCNALTIEB FOR SUBMRTING FALSE INFORMATION INCLUDIH('. / <br />r • ~ !!! / <br />~ / <br />THE RbslBttRr Di FINe ArvD .MRP40NMEnT .SEC le USC 411bt ArvO <br />- ~ 'i ]] U.C 11319. rPrIInLv. uMrr r~rw rmwfF. w.a nrludr /Int. u4 I•• rPUm BIGNATURE OF PRINCIPAL E%ECUTIVE ~J) ~. ~,/ t! <br />~ - - <br />_ <br />TYPED OR PRINTED a•W.•.ma.~nnun.myn.~nm.nl u/I.~I...nfiwlunlA. and.:.wr.l OFFICER OR AUTHORIZED AGENT '! 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