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PERMITTEE NAME/ADDRESS (l+.Ae.r«ugNawtamm, Uo~,.en/
<br />NAME l' .-.: ~ ,. ..: ... Y
<br />ADDRESS ~ ~' '-'' - -•
<br />FACILITY
<br />LOCATION I'. I! ~ ~ \ '_ ii G ] •, ;
<br />NATIONK POLLUTANT DISCHARGE ELIMINATON SYSTEM (NPOES)
<br />DISCHARGE MONITORING REPORT IOMR)
<br />?-I61 17-191
<br />.,,77601'] CCs A
<br />PERMIT NUMBER - DISCHARGE NUrABER
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<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM y. '_ TO
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<br />PARAMETER !$'Grd Onlyl QUANTITY OR LOADING /a rd Onlyl QUANTITY OR CONCENTRATION NO. FREOUENCV SAMPLE
<br />371
<br />I31 !0653/ l5d-BIl l3B-a5 /4653 /Sd-B11 EX OF TYPE
<br />- AVERAGE MAXIMUM UNITS ' MINIMUM AVERAGE MAXIMUM UNITS
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<br />169-701
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNOFA PENKTY OF UW THAT I HAVE PERSONKLY E%AMIN
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BA ED AND
<br />SED ON
<br />~' TELEPHONE DATE
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<br />MY INDUIRY OF THOSE INDINDUKS IMMEDIATELY RESPONSIB
<br />OBTNNINO TXE INfORMATION
<br />I BELIEVE THE SUBMITTED INFORMA
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<br />TION IS /
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<br />AOLURATE AND COMPLETE
<br />I AM AWME THAT THE RE ARE ~ I '^i .
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<br />SIGNIFICANT PENKTIES FOR SUBMITTING FKBE INFORMATION
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<br />1 THE POSSIBIDTY OF RNE AND IMPRISONMENT. BEE 18 U.B.C. f 1001 AND 3J
<br />BIONATURE OF PRINC
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<br /> U.B.C. E 1510. IAYrWS• ulsw drr mrlm.'+rr bdw. rw. w m f IO,D00 I AREA
<br />TYPED IOR PRINTED end «muirx.n fHplsnrlv+f W Nrwwn SmmeM W e ywa/ OFFlCER OR AUTN BRED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRe/erence el/sttschments here/
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<br />EPA Form 3320-1108-951 Previous editions mey be used. IREPLACEB EPA FORM T-40 WHICH MAY NOT BE USED.1 - i ) / <, -/ I ~ .] i - 1 5 1 i PAGE iOF
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