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PERMITTEE NAME/ADDRESS OneYd. FxrGry Nawdf<ranon!/OfEewd
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<br />NATIONAL POLLUTMT DISCNMGE ELIMINATON SYSTEM INPDESI FO1m Approved.
<br />DISCHARGE MONRORING REPORT IOMRI ~~
<br />12461 177-E91 ' ~ ~_ ~ I' - - - "~ OMB No..20~40-0004
<br />_ _ . ~ ~ , . (~ L, ~ ,, `'- - - ~- APProvel:eipiree OS-31-9&
<br />PERMIT NUMBER DISCNMGE NUMBER _ L ;%
<br />MONITORING PERIOD ~ ""
<br />YEAR MO DAY YEAR MO DAV
<br />FROM . 7 L J7 TO ~ .:._ l: '/_ -` - . • (! I .~; '.
<br />126111 112-131 /2b151 !1617/ 129-191 /3631) NOTE: Reed Inetruetlaru belore completing thb form.
<br />PARAMETER 13 Cerd Onlyl QUANTITY OR LOADING 11 Grd OnlYl QUANTITY OR CONCENTRATION NQ FREQUENCY SAMPLE
<br /> /46531 15b6/1 I38-d51 !4653/ 1546/ EX OF
<br />/31-371
<br />MMY515 TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS lR1.63! IbA-661 !63701
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<br />NAME(fITLE PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDER PENALTY OF UW THAT 1 HAVE PERSONALLY EXAMINED MD TELEPHONE DATE
<br /> AM FA MILIM WITH THE INFORMATION SUBMITTED HEREIN; MD BASED ON
<br />- ~ Mr INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FDR
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<br />'" ~ ~ ~ L' V `~' ~ ~' OBTNNINQ THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS / _ _
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<br /> TRUE. ACCURATE MD COMPLETE. I AM AWME THAT THERE ME
<br />SIGNINCANT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING {
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<br />THE POSSIBILITY OF FINE MID IMPRISONMENT. SEE 18 U.S.C. 1 1001 MD 33 I~. 810NATURE OF PRINCIPAL EXECUTNE ~' ~ ` ~ ` " E~' 1 " ' ~
<br /> U.S.C. 1 1311. (PeWllrtr vWr eMr trutulrr nMY YKAAN lYrr 1e m ! 10,000
<br />TYPED OR PRINTED eM a~maYnwninprlemlrN Or an.Nnemena, rNeyrA•AI OFFICER OR AUTHORIZED AGENT CO E NUMBER YEAR MO DAY
<br />CVMMEN IS ANV [nr~nnn narn yr nnr Ylv~n nvna lnelrrmcr an euecnmenrs Here/
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<br />EPA Fam 3320-1 (08.951 Previous editiorre meY be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) 1 ^ , pgGE OF
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