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PERMITTEE NAME/ADDRESS pnclude Faciliry NamNLormion if Di$erenQ
<br />NAME ~OUI r ,. ;,y,. ~:,,• I ,. 1.: . r ,,.~
<br />ADDRESS RONI ~~ Yri, r ,I T ti r.
<br />P.!7. H~'X y t t
<br />PA[;nIA ('~. 314 29
<br />FACILITY -
<br />LOCATIONROE ? t. ^O 82 U 29
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<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM MFDES)
<br />DISCHARGE MONITORING REPORT (DMR;
<br />p-16) (I]- 9)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 00 07 DI TO ^D OQ ~
<br />(76311 (21-23) l24-151 !Z&11) !Zl4Y91 l30J11
<br />Form Approved.
<br />~ T , , ! OMB No. 2040A004
<br />Approval expires OS31-90
<br />(St7 F:P JC)
<br />'' - P' 4aL fi3LTA
<br />n~r-RC C`f 54 TO DF.F4 'TR~..L +7'"C't
<br />NOTE: Read Instructions befor~TAhl~letlnG this form.
<br />PARAMETER (3 CertT Ony) QUANTITY OR LOADING (4 Card Ony) pUANTITY OR CONCENTRATION N0. FREOUENC SAMPLE
<br /> (46-53) (54-61 (3845) 46-53) (5a~B1) p( OF TYPE
<br />(32x7) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />(ezm) ANUrsrs
<br />(64-68)
<br />69-70
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<br />r FF'LfIENT I;YO`~ ~ YA?.U REQUIREMENT ° ##^# ~ ' ~ iT ~
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<br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO NALLY EXAMINED ANO TELEPHONE DATE
<br /> AM FAMILIAR WITH THE INFORMATON SUBMITTED HERE IN; AND BASED ON MY
<br /> INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING ~/
<br />
<br />J
<br />1 THE INFORAA44~~TION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE,
<br />ACCURATE ANp COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT
<br />PENALTIES F R SUBMITTING FALSE INFORMATION
<br />INCLUDING THE /~h ~/~ .
<br />G r
<br />
<br />,.~i/ I ~'J /~'{~~: r \. / t ,
<br />VOSSIBILITY OF FINE AND IMPRISONMENL SEE 7B U.S.C. § 1001 AND 33 U.S.G
<br />SIGNATURE OF RRINCIPAL EXECUTIVE /~ ,
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<br />TYPED OR PRINTED § 1319. (Penshles antler these sleBnes msy Inclutle lures up ro Ef0,000 rNtl w
<br />muimum/mprlsonment or beMSen6mpnfrt5 entl5yeers.) OFFICER OR A{lTFiOftIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />"~ZTTLEABLE S7LLuS LICIT APPLIES ~hLY IF <=10YN,74HR PRECLP FVFVT i5 !'GATC~D. TF rLAIY APpFOY^D FY '>~-C(`,
<br />~.5_, E IROtI LI!!ITS YIiL NOT HC APPLIED T7 9EPORTED MEASURSMF.'rTS-SF.R LA.2, PC c F09 RUArPttr,F pa0cr
<br />EPX;orm 3 0 - Previous a Itions may no' be use ~ ~ `" • ( p CES A F T' I NO E E .) o'T ~ 3 % ; 7 0 ~ T ,- ~ ~' ? PAGE , OF
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