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PERMITTEE NAME/ADDRESS O1d.d. FrtAryNwWLrwm UD~..+.0
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<br />NATIONAL POLLUTANT OISCHMGE ELIMINATION SYSTEM (NPOESI Form Approved.
<br />DISCHARGE MONITORING REPORT IOMRI , .OMB•No: 2040-0004 ~.
<br />!7-Iel 17-191 ~ ~ . '• - I
<br />. ~ -. 7 i .. 1 ~ / .- . ., Approves expires OS-31 ~98
<br />• !PERMIT NUMBER DISCHARGE NUMBFA ~ ~ T e .
<br />MONITORING PERIOD '
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~ TO ~ .. . , _. ~ ~ ` - I . ~ .
<br />116111 111--131 17r-151 /76171 !IB-191 (363/1 NOTE: Raed Inatruetiona before complatinp thin form.
<br />PARAMETER 13 Grd Onlyl QUANTITY OR LOADING !I Grd Onlyl QUANTITY OR CONCENTRATION NG FREQUENCY SAMPLE
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<br />r31-37/ 515
<br />AN TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS lsi~sst l61-581 169-701
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cl[RnFr UNDER PENAIrr OF uW THAT I HAVE PERSOHUI.r ExAMw¢o ANO TELEPHONE DATE
<br /> AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON
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<br />SIGNIFCANT PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br />TYPED OR PRINTED rMrmuirP.rt Mpda~a,wnrNMnrwn sn:rrrA. rNey.ra! OFFICER OR AUTHORRED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRSfsrsnes sl/ sttscnmenfe hers!
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<br />EPA Form 3320-1 108-951 Previous editions mey be used. (REPLACES EPA FORM T40 WHICH MAV NOT BE USED.( , .., T . - ~ - _ _ PAGE . OF
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