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PERMITTEE NAME/ADDRESS (I,d,4 FacYlry N.r/Laaum l/D/s..wl
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<br />NATIONAL POLLUTMT DISCHMGE ELIMINATION SYSTEM INPDESI Form ApPEOVed.
<br />DISCHARGE MONITORING REPORT (OMRI „. ~ ~ . -~ . -IOMB•No: 2040-0004- ••
<br />II-l61 l17-191 -
<br />-, ~ ., ; 7 ~ .~ ., ,. ~ t Approvd expires OS-31.98
<br />_ PERMIT NUMBER DISCHMGE NUMBER •' ~ r
<br />MONITORING PERIOD -
<br />YEAR MO DAY YEAR MO DAV -_
<br />FROM ~ ! ~ '. TO ...: .. ~ ~ .-,•
<br />170.7/1 l77-731 !74751 !16771 l76-191 130.3// NOTE: Reed Inetruetlone before complatinp this form.
<br />PARAMETER !3 Grd OnlYl OUANTfFY OR LOADING I4 Grd Ontyl QUANTITY OR CONCENTRATION NO RtEGUENCr SAMPLE
<br /> !0653 !5461) /38-461 !1653 !54611 EX OV
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<br />(97-371 SIS
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<br /> AVERAGE MA%IMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !6/.697 16a-6B1 169-701
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cERnFr UNDER PENALTr GF uW THAT I HAVE PERSONALLY EzAMiNED AND TELEPHONE DATE
<br /> ALI FAMILIM WITH THE INFORMATION SUBMITTED HEREIN; MD BASED ON -
<br />i'~CII i~C; i, IILI~ My INQUIRY OF THOSE INDINDUKS IMMEDIATELY RESPONSIBLE FOR ,
<br /> OeTNNING THE INFORMATION, I BFLEVE THE SUBMITTED INFORMATON IS
<br />I'I-1VIYOCi F'°:T1 :I ,.li: il50°!
<br />/•' TRUE, ACCURATE AND COM0.ETE. I AM AWME THAT THERE ME
<br />SIONIRCMT PENKTIES FOR SUBMITTING FALSE INFORMATION
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<br />THE POSSIBIDTY OF RNE AND IMPRISONMENT
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<br />l SIGNATURE OF PRINGPAL EXECUTIVE
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<br />TYPED OR PRINTm mar muirenr YrlpYawrltW Mnrwn emonN.W 6 rANa/ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANA ZION UN AnT vtuLA I Iurva lrtererencs ai emcnmenrs oars/
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<br />EPA Form 3320-1 108-851 Previous editions may be used. /REPLACES EPA FORM T40 WNICN MAY NOT BE USED.1 „ „, , r 7,• .: r , - -r _ , „ - PAGE - OF
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