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PERMI'fTEE NAME/ADDRESS R.d•iFrl4ryNr/LOx•Na dD1~+•q <br />NAME <br />ADDRESS 1- e . _ , ~ ~ I . ~ -. T T <br />i' • .,, . <br />- ;,.^. , <br />FACILITY r <br />LOCATION ~ ... ~ '. . <br />~~. <br />NATIONK POLLVTANT DISCNMOE EIIMINATON SYBTEM (NPOES/ iU::. ~..4'JUVetl. <br />DISCHARGE MONRORING REPORT lOMRI OMB No. 2040-0004 <br />11-161 77-19 .. T . ~ .. <br />_ Y ~ Approvel'azpiree 05.37-t~8 <br />PERNIIY NUM9ER accliuluE NuMBm ~ •~ ~' ~ ~ { <br />, - ! <br />=.j ~' " MONITORING PERIOD r'~ " <br />YEAR MO DAY YEAR MO DAY <br />FROM .; I ~ . ~ TO ~ , ~ .. - , _ _ <br />lP67I7 121-131 I36Z61 !7677/ rS8-7B! /36371 ~ NOTE: Ri^d'Irb1N'Ctla"1M b^fan{celRpNtlrip thb form. <br />PARAMETER !3 Grd Only) QUANTITY OR LOADING !I Grd On1y1 QUANTITY OR CONCENTRATION NO FREOUFNCY SAMPLE <br /> !44531 151-51 l36-151 x653 66611 GF <br />f37-371 EX <br />ANKVas TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNI75 !sl-^T !56661 !6970/ <br />- L ,_ SAMPLE <br />~ ~~~ -" ~` " ~ <br />~ <br />' ~ " ~ " <br /> MEASUREMENT <br />S ; <br />. <br />PERMIT <br />. L ,~ .. ~! .^4:': :p OI;'.'IJ t <br />'I ,a] ~: :.x'w4#:x :,T :':'L~tk <br />°:: ~' is i;:.: ~::+,i :~ <br />~ .. ... <br />«' <br />~ C <br />i it <br />' <br />' I ` <br /> 'REQUIREMENT . , ~ s :, <br />, . <br />. <br />'i r: ..w ~s <br />_ <br />, <br />_ _ SAMPLE ~ ~~ _ I <br />• MEASUREMENT ~ <br />f <br /> !e <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 /> ~~!! <br />` <br /> PERMIT .. ~ <br />. f~.CjG <br /> REQUIREMENT ~ ~ ~ ~ . <br />. <br />~ ~ (1 <br /> SAMPLE Ca y <br /> MEASUREMENT GV ~ <br /> PERMIT ~tf~1 <br /> REQUIREMENT ~ ~ ~ I ~~ O <br />~~S~OI• <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME?('fLE PRINCIPAL EXECUTNE OFFlCER I CERTI <br />AM FA FY UNDER PENKTV OF <br />MILIAR YNTN THE INFO LAW THAT 1 HAVE PERSONALLY EXMIIN W AND <br />RMATION SUBMITTED NDIEIN~ AND BASFD ON <br />J <br />/ %~ '"' ., <br /> <br />~ / TELEPFIONE DATE <br />I . I <br />I . L I r h ~) a {~ t (` MY INQUIRY OF TNOSE INDINDUKS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION <br />1 BEl1EVE THE SUBMITTED INFORMATON IS '~ <br />/ <br />/ <br />/ ~ " <br />~ <br />/~ <br />~ , <br />TRVE <br />ACCURATE AND COM0.ETE <br />I AM AWARE THAT THERE ARE _ <br />/~ <br />I , <br />. <br />SIGNIFICANT PENKTIES FOR SVBMITTINO FKSE INFORMATION <br />INCLUDING / <br />~ <br />1 <br />I{` <br />I 0 /~ , <br />THE POSSIBIUIY OF RNE AND IMPRISONMENT. SEE 18 U.S.C <br />1 1001 AND ]i <br />~ _ _ <br />~l <br />~ l <br />rl - <br />„ . <br />1 1 ]1^ <br />U <br />S <br />C <br />lMWt4 <br />4 <br />B <br />! 610NATURE OF PFIINCMAL EXECUTNE I ' - ~ ! <br /> . <br />. <br />. <br />. <br />. uKw Urr IYNM1A m•Y <br />N«b <br />rN. W ro <br />10,000 <br />TYPED OR PRINTED waman.R.n lnplronnwledsMrwnemwrlN ^ndByrra/ OFFICER OR AUTHORIZED AGENT CODE NUM[1ER YEAR MO DAY <br />CVmmcn I a nnu cAr•~nnw I Ivn yr arc x YwLn I rvna Irtsr^rsnce sn ^rr^cnmana Dae/ <br />~.I,~~. !. "i ILL L" ~ - I . , <br />1 <br />Epp Farm 13'2 1 108-981 Previous stliriorni m y tie u^etl. ~ . ~' IREPLACE6 EPA FOR T~0 WHIC MAY'NOT BE USED.1 •~ ~ - ' • • F PAGE OF <br />