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<br />NATIONAL POLLVfMT DISCHMOE ELIMINATION SYSTEM (NPDESI
<br />DISCHARGE MONITORING REPOpT (OMR1
<br />l7-I81 17-191
<br />PERMIT NUMBER DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAV
<br />FROM V '! ;1 } !! 7 TO y Y G I
<br />!16711 l72-731 !7415/ !7677/ l78-791 136371
<br />Form Approved.
<br />,- ~ ! ,1 1 , , L ' ; - OMB No. 2040-0004
<br />~ . 'J ' ~ ~ r. S Approvd expires OS-31-98
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<br />NAMERRLE PRINCIPAL E7(ECUTIVE OFFlCER 1 CERTIFY IINDFA PENALTY OF
<br />AM FAMWM WITH THE INFO UW TMAT 1 NAVE PE1150NALLY El(AMINm MD
<br />RMATIQN SUBMITTED HERDN; MD flASED ON
<br />~t TELEPHONE DATE
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<br />OBTNNINO THE INFORMADON, 1 eELENi THE SUBMITTED INFOW.IADON IS
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<br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br />Gr rl, _ ~ !JI [i THE PASSIBILITY OF RNE MO IMPRISONMENT. SEE to LLS.C. E 1001 MD J3
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<br />SIONANRE OF PRINCIPAL EXECUTIVE ~ 7
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<br />TYPED OR PRINTED rNrnr¢hunanprismlvaWMtrwn e,rvxM rd6yrnl OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Reference e8 eMechmenfs here)
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<br />EPA Fwm 3320.1 108-95) Previous sdiGons mey be used. /REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) is _ / . . I I } ~ _ ~ } , y PAGE t OF
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