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PERMITTEE NAME/ADDRESS (/nc(ede Fan(iry Nmee/LocaHOn lflhgeenr)
<br />NAME 1.; 4~".:K „T., Z'iC, 1•. /'•
<br />FACILITY ~~ H I,; ::1 '+i'. Z'•
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) FORA ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMA) OMB ND. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER -. _
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER ICertlfy under penalty of law tlw this document antl all ettachmenb were
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<br />d TELEPHONE DATE
<br /> a syslam designe
<br />prepared antler my directlon or superwsion in accordance wis
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<br />W. Gordon Per-ere to assure Net qualifietl personnel properly gamer entl evaluate the infonretlon
<br />aubmR[etl.BaeedonnrylnqulryolmepeBOnorpersonawhomenegetheryslem,
<br />G- ~ ~je~-~ 9'•0-824-4401
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<br />President/Geueral Manager ormwe persona tllreelly responsible br garnering the WOmletlon, meinlomatlon
<br /> aubmktad Is, W the beatd my knowledge entl belief, true, accurate, entl complete. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED I em aware that mere em slgnifiram penaltlea for submming felae inbrmetlon,
<br />includlnc the oossiblliN of fine and imprisonment br knovrind violatlons. OFFICER OR AUTRORIZED AGENT
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />r+n~.uenlTC eun eYPI ANATIhN (1F ANV Vlfll ATI(1NS /Rwlwmnew wll aMachmwntc hwrwl
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<br />[F: .iU ~. L:'4 OE' Pr{UJF :+E':JIii is `~;::!?"_: Uli~. ii I. n. 3. '.'C: _`iIT6RING - T. .3. ..`:. ,.. - _.. i. (D).
<br />EPA Form 332 1 ~(R 9) revious e I ons'may a used. '" - ~ ~ ~ = T,~-IIS IS A 4-PART FORM PAGE OF
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