PERMITTEE NAME/ADDRESS pnclode Faci(iry Name/Lacanon i/Dif/nmQ
<br />NAME hGMIE HE_4t.UbCc:. 11CLI_L
<br />ADDRESS ._ ,; ~~ j i'. N .'.. ~ " 1 F I
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />(2P21) (2223) (2x25) (26.21) (28-29) (30011
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<br />Form Approved. ~,
<br />!' I N C F OMB No. 2040-0004 .
<br />Approval expires 05-37-9R
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<br />PARAMETER (46-53) (54-81) (3B<5 48-53) 54-87 EX OF TYPE
<br />(32.37) AVERAGE MAXIMUM UNRS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL IXECUTNE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON AIY ~ TELEPHONE DATE
<br /> INQUIRY OF THbSE INDNIDUALS IMMEDIATELY RESPON
<br />THE INFORMATION, I BELIEVE THE SUBMITTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE,
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<br />I AM AWARE THAT TH ERE ARE SIGNIFICAM a
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<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 16 U.S.C. 4 1001 AND 33 U.S.C.
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence ell attachments here)
<br />._rCHT "NCI"' (AC CtLCFIA~F. TREATrT) IF ~G CHICFLNF LSEC--SEE G/. CIL P,' ;PEASE - I.F.1.C, FC. E.
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<br />EPAti orm 3320.7 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) ~ , C C C C S / 9 S C i 1 t - 1 `_ i f
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