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PERMITTEE NAME/ADDRESS pri,4 frW yNw/I<ceum,/D,di.wq
<br />NAME .~ •.i ~1 :.. ~ ~ .. .. ,
<br />ADDRESS ; I •_l . i ~ ' '
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<br />FACILITY I: ~ ~ i .,
<br />LOCATION ~ I
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<br />NATIONAL POLLUTANT OISOHMOE ELMINATON SYSTEM INPDESI
<br />DISCHARGE MONITORING REPORT (OMR1
<br />l1-161 17-191
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<br />PERMIT NUMBER DISCNMOE NUMBER
<br />' - ~ ' MONffORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM I ~' 1 - 1 ~ TO ~ i
<br />' - !161/1 /11-131 !II-151 !16171 !7B-I9/ !36311
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<br />Fonn Approved.
<br />~.OMB.No„2040 ~4,
<br />Approval -ezdire4 03-~ (98
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<br />NOTE: Reed Inetructlaru bet«~ LRIFhpbtinq this form.
<br />PARAMETER l3 Ord Onlyl QUANTITY OR LOADING !1 Grd Only/ QUANTITY OR CONCENTRATION NG FREQUENCY SAMPLE
<br /> l~6531 154611 l38~51 !16531 !64611 DF
<br />l31-371 EX
<br />MALY45 TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rr1.s3) !64661 !63701
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<br /> REQUIREMENT
<br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF UW THAT I HAVE PERSONALLY E%AMINED MD TELEPHONE DATE
<br /> AM FAMILIM WITH THE INFORMATION SUBMITTED HERflM; MD BASED ON
<br /> MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> OBTNMING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br /> TRUE. ACCURATE MD COM0.ETE. I AM AWME THAT THERE ME ,, ~ ..
<br />' SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLWING ~ -
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<br />r THE POSSIBILITY OF NNE MD IMP11150NMFNT. SEE 1B U.S.C. ! 1001 MD 33 BIONATURE OF PIIINCIPAL EXECIfTNE ~ ~ '
<br /> U.S.C. E 131 B. lPOrle•• IN•r IMA• 0NF•a r«Y NrArd• rxw• W ro E 10,000
<br />TYPED OR PRINTED rM nmuirN•n iryYlowwrrt e/brw••n smondu •ne s Y•ra) OFFICER OR AIlTHORRED AGENT CODE NUMBER YEAR MO DAY
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIOnS IMBrrrenn sn snecnmenn nsre/
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<br />EPA F«rim"332'0• 108.961 Pievioue~sditione mey'bd'ireed.! /REPLACES EPA FORM T-00 WHICH MAY NOT BE USED.1 PAGE OF
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