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PERMITTEE NAME/ADDRESS Qnclude Facdiry Numellornriun ilDrfferenQ NATIONAL POLLUTANT DISCHARGE EDMINATION SYSTEM (NPDES)
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />531 STATE HIGRMAY' 13 PERMIT NUMBER olscyngGENUNIBER
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<br />~ A'ti~AY TG AORR AREA FORD
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<br /> (3 Card Onty) QUANTITY OR LOADING ~fG'Card Onty) • QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53f (54-61) ~ [+~~' (3R-45) _ (46-53) (54-61f EX OF TYPE
<br />(3Z-37) AVERAGE MAXIMUM UNI~ MINIMUM '~.~AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND /\
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<br /> AM FAMILIAR WRH THE INFORMATION SUBMITTED HEREIN; AND BASED ON MV /
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<br /> INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING (
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<br /> THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE, '
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<br />n ~ ~T rl ) PENALTIES FOR SUBMITRNG FALSE INFORMATION, INCLUDING THE
<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1a U.S.C. § 1001 AND J3 U.S.C.
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<br />TYPED OR PRINTED § 1319. (Penarties under these sfalNes may include Imes up 1o E10,000 end or
<br />maximum impdsonmenl ol6eA.sen6months antl5years.) OFFICER OR AUTHORIZED AGENT AR A
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Helerence ell attachments here)
<br />";OhIT03IyG REGUIRE:7ERTS iF.F, I.P.1.R, PCx. 5. fSIJRDF.9 rP PROOF ~ RE~'fi~IAEltL°NTS - ?f:F I.A.2, FG. +l.
<br />EPA Form 33247 (08.95) Previous editions may not be used. ~., (REPLACES EPA.FORM T-40 WHICH MAY~NOTBE:USEDJ,
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