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PERMIT'fEE NAME/ADDRESS Prri,sr FrWryNSw/focplur IJDrpirw) <br />NAME 1 .) n ! ~ I <br />• ~ .~ <br />ADDRESS ,r.J n (.. ..1 • _ . . <br />!'. ,. 1. , <br />FACILITY ~ • _ - <br />LOGTION <br />.~ . _ / <br />NATIONAL POLLUTANT OISCHMOE El1MINATON SYSTEM (NPDESI <br />DISCHARGE MONFTORING REPORT IOMRI <br />1-161 117-191 <br />' i'~. n'+1.I <br />PERMIT NUMBER DISCHMGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAV YEAR MO DAV <br />FROM ~ ' 1 ~ ", i TO • . y ! <br />126271 772-231 I1t-151 17627) !IB-19/ I363I/ <br />Form Approved. <br />„Ob9.No„ 20,40-0004 <br />t( ~ \~ l' r ~ '_,1 ~-.i ^ - ~ Approval ~exP.iree'OS-3Fl tS8 <br />1 _ ~ n:. <br />. .... 4 ,~ _ r I -_ I <br />NOTE: Rsad Instruwiom balws L•dlhplatlnp this form, <br />PARAMETER l3 Grd OnIYI QUANTITY OR LOADING 11 Grd Onlyl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> 116-53 I5s-571 138-151 It653 151-61 DF <br />731-371 EX <br />MALrsls TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS Isz-69! 15458/ 169-701 <br />!:, A•.-. ,.. ...' SAMPLE -; r:. .. <br />.< { .I fO .. .. . r: .. ;.:. ;..: <br />.. <br />~~: • <br /> <br />.~ <br />~ <br />MEASUREMENT <br />-t' . I/- : <br />S <br />; i <br />i <br />-., .,0 . J 'l <br />. PERMIT r-:C-;:^w.~ <br />~ `R r'PJ~P i ,=1 ;r:+..r. ..,. .. rSt. r •: r.; 'v=isLT i is x,. <br />:. a I. I . , ? )'; ; ': p. t ; <br />. f : 'REQUIREMENT <br />8 <br />a A <br />F, ~_ . <br />• SAMPLE <br />MEASUREMENT <br /> . PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />• MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENN.TY OF L AW THAT I HAVE PERSONN.LY El(AMINED AND TELEPHONE DATE <br /> AM FAMILIM WITH THE INFO RMATION SUBMITTED HEREIN; MD BASED OM <br /> MY INQUIRY OF THOSE INDIVIDUALS IMM WIATELr RESPONSIBLE FOP <br /> OBTNNING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATON IS <br /> TRUE, ACCURATE MD COMPLETE. I AM AWME THAT THERE ME <br />SIQNINCMT PENKTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING ,`yr <br />.• ° ~ " <br />~ ~ ~. <br />' <br />V <br />' , <br />THE P0551BILITY OF RNE MD IMPRISONMENT. SEE 18 U.S.C. E 1001 MD 30 eIONATURE OF PRINCIPAL EXECUTIVE ~~~ r ~ 4 <br /> <br />TYPED OR PRINTED U.S.C.11Jte. lP,1Wtls YMr dMr ,srvr•, 1wY Ndrd~rw.,WbSIO,000 <br />.~e..nr.YNS,n irpn'owwnr Pl fwtw•snem,nsr, rg5yral <br />OFRCER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAV <br />COMMENTS AND EXPLANATION OF ANY VIOLA nONS (RS/sronea s/I attecnments hale! <br />- ~) ~ :. -. .. ~ _ .. J ). i ~ ' ~ 1 ~ : a ~ > r I ~:, 1i L . - .) "r i. Y i i ri = i ', ~ - / ' : r i q - ? :: ... -. i . :. Y L h i ~ '- f' r . •~. i ..... i • i ~ , . 7 f : i - i... -~ , <br />. f r1 d~J• ~.1 , ~ .J' !-ul l .+l i. .. 1~ .. /1 C'fu~v '-q ,I r.J.. . , ....A-, ,. .. u.. --.r1 •.~~ a• •l.t r • • •- <br />• I ~ <br />EP Fwin'3320- (08.96)' Previous"editiotis riley bA'ueed. -' ~ IREPLACE6 EPA FORM T-0O WHICH MAY NOT BE USED.) PAGE OF <br />