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PERMfTTEE NAME/ADDRESS (Include Faciliry Nwne//acafion ijD$erenq
<br />NAME TVI:'." vr' 7'i.I. 't °^4L _^nr.
<br />ADDRESSMTII 5 1, 1: _' "'^'; "'~r ~: c^~-~•; rr
<br />'{.100 F!1°o ,T, ~ - ^rn^T :~
<br />~NGLEaD]^ '.]1S:
<br />FACILITY
<br />LOCATION
<br />..-.. COr?1{IS L. 'GLv, "°tl"-al, nTSP
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPOES)
<br />DISCHARGE MONITORING REPORT (DMR~
<br />(2-16) ft]- 9)
<br />'_]6'1'716u n1^ n
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM - I" -' L TO '' ' :' ' `"
<br />(26211 (22-23) (2425) (2F211 (1829) (3631)
<br />Fonn Approved.
<br />OMB No. 2040-0004
<br />,, 1 Approval el~ires 05-31-fl0
<br />+ ANOTE: Read IrlsVUCtions before completing this forth.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 46-53 (54-81) 3815 48-53) (54-61 D( OF TYPE
<br />(32an AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />6370
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT 1 HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY ~ /;
<br />= / TELEPHONE DATE
<br />
<br />~:(C('IDrL~ fVl)II$ INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION
<br />I BELIEV S IMMEDIATELY RESPON
<br />E THE SUBMffTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE, .
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<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTIN I AM AWARE THAT TH
<br />G FALSE INFORMATIO ERE ARE SIGNIFlCANT
<br />N
<br />INCLUDING THE /
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<br /> POSSIeILRV OF FlNE AND IMPRISONMEM. SEE f e U.S.C. 51DD1 AND 33 U.S.C.
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<br />' SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED 5 1318. (Prnela
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<br />es antler Nave amtNes mey
<br />es up m f70,000 sntl w
<br />rwimum ~mpdswvrrers of betwsenBmont/u entl5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell ettechmenLS here)
<br />S:rTLF:n;1'.,. ']LC'I~ rTwT.. I~ {4~yrn li.T'. •nel ]\L~ I° >T~-!•^e 7!1-Tln JOPnTn ^,/nVn TS ~LiT°~^• .~~'
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<br />EPA Form 33241 (115.95) TPrevious editions may not be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) n n T n T ~ ~ T n 11 ( n-T S ~ II PAGE ~ OF
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