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pERMITTEE NAME/ADDRES$pnclude Faciliry Name/Cocmion iJDifferen!) NATONAL POLLIfrAM
<br />NAME DISCHARGE
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<br />ADDRESSyOii I C tin, ~ ~• f •, •. ~
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<br />1TION SYSTEM MPDES) Forth Approved. 4
<br />SORT (OMR;B) ' OMB No. 2040-0004
<br />I *I OQ Approval expires OS-31-98 ~ ,
<br />(S!I3B .C)
<br />DISCHARGE NUMBER F-° T N 4 L C I; E,'j A
<br />RIOD ~SC'{C CF ~fl T~ C?ER TRAIL ^'"C `I
<br />TO q9 D t<": V^ C'. SCiI~P.fY tt ''
<br />(zq-zs) (zuzT) (ze~ze) rawt) NOTE: Read Instructions betor4 ~Tleting this lortn.
<br /> (3 Card Ony) OUANTI RL ING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 46-53) -61) (3846 (46-53
<br />) ) (64-6,)
<br />EX
<br />of
<br />TYPE
<br />(32-3n AVERAGE IMUM UNITS MINIMUM AVERAGE MAXIMUM UNfTS
<br />(szeT) '~'~1S
<br />(6x-68
<br />69-70
<br />p•4 SAMPLE 'mil=.wR# .:k :0#t ;rt~.~.. ( ~ 2)
<br /> MEASUREMENT
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<br />5- ~ p }: N D E U MEASUREMENT
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<br /> MEASUREMENT
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<br />(AS PEi MEASUREMENT
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<br /> MEASUREMENT
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<br />SOLIDS, TOTAL SAMPLE 'S:Y'.='.sr:T t=fi°•:.':: ¢'~^"-"? ( 19)
<br />liISSOLYED MEASUREMENT
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%AMINED AND
<br />IN
<br />AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, 1 BELIEV ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE,
<br />~~
<br />~ -
<br /> ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITRN I AM AWARE THAT THERE ARE SIGNIFICAM
<br />G FALSE INFORMATION
<br />INCLUDING THE „
<br />~
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<br />
<br />/~( /! /j! ~ ~ EfI '-
<br />POSSIBILffY OF FINE AND IMPR ,
<br />ISONMENT. SEE,B U.S.C. 4 1001 MID 33 U.S.C.
<br />SIGNATURE OF PRINCIPAL IXECUTIVE /~
<br />7 ~' /+ v~
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<br />TYPED OR PRINTED mau um~pnsmmerKOr oe~i eonemontre entl gutle lures up bElo,000 erMm
<br />~/ OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS ANU EAYLANAI IUN VH ANY VIULAI IONS (Reference 9/19(f9CD/rlen(S nBreJ
<br />'.};iTLEAIiL[. SOLIUS LIMIT APPLL@S OvLY IF <IUYA,7UHR PRF.C7P PYF,9T IS C.L0.I'"°'D. IF CL AI" 4PPACYF'1 .'Y V;C^,
<br />:S;i IRON LItliTS PILL ROT 3F. ApPLL?D TO REPORT?D [1f:ASUREPE'.VTS-SPE I.A.2, Pr, 5 FOP R~RDry t'F P4`lOF
<br />A'Form o• ~5- Pr wouse itio ' n b ~e .' • `• EP CES W (i AY ~ S '- • ~ PAGE OF
<br />OO~r13/990T1 J-1177 1
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