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PERMITTEE NAME/ADDRESS (Include Facility NmndLocerion iJDfferenQ
<br />NAME
<br />ADDRESSp k .4 i P u• p. r •~
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<br />FACILITy`u ~ T': ";1 y I r, i S
<br />LOCATION
<br />NATONAL POLLUTANT DISCHARGE ELAI1NATgN SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR~
<br />R-te) p1- e)
<br />^ PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 9 R 1 2 71 TO ~ ~ 1? ~ l
<br />Forth Approved.
<br />^ t •I r) 4 OMB No. 2040-0004
<br />Approval expires 0531-98
<br />(C'rno bu)
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<br /> (3 Certl Ony) QUANTITY OR LOADING (4 CeN Ony) OUANTIIY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4653 (54~T) 3845) 48-53 (5487
<br />EX
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<br />TYPE
<br />~~~ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANaLrsrs
<br /> (ez831 (64-68 8370
<br />:i SAMPLE ^.?sass TCa.•'.!a r:^Ys,9k~ 1 .?)
<br /> MEASUREMENT
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<br /> MEASUREMENT :I
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<br />.pU TH+!4TK''NT t'LA "n• MEASUREMENT
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<br />~,I`.~`iOLY~D MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER i CEHTI Fr uNUER PENALTY OF LAW TnnT I HAVE PERSO NALLY E7AMIN ED AND TELEPHONE DATE
<br /> AM FAM ILIAR WffFl THE INFORM ATION SUBMITTED HERE IN; AND BASE D ON MY
<br />
<br />W. GOrdOD Peers INQUIRY OF THOSE INDNIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E 1HE SUBMITTED INFORMATION I$ TRUE,
<br />T
<br />/~~~~ .L~"''
<br />-
<br />/°~'
<br />President b General :4anager ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTNG I AM AWARE
<br />HAT THERE ARE SIGNIFICANT
<br />FALSE INFORMATION, INCLUDING THE /
<br />0 824-4401 9 1 5
<br /> POSSIBILfiY OF FINE AND IMPRI SONMENT. SEE 18 U.S.C. § 1 W1 AND 39 U.S.C.
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<br />~~ SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />n OFFICER OR AUTNORRED ACEM
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<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Relerence all a[lechments hale)
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<br />Form ~0.i~(b~s ) Previous editions may not bA' used. ~ ' ~ ~ (REPLA S EPA FORM f-00 IC MAY T BE USED.) PAGE
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