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PERMITTEE NAME/ADDRESS preYbs'rWryrv~.'laen~. UDIpG.erp
<br />NAME ,.~~, :. •.d .. :ie :. .. ,. ,
<br />ADDRESS ~=~^ " • =
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<br />FACILITY
<br />LocAnoN ., , ~ ? 910 3 J
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<br />NATIONAL POIIUT/SIT DISCNAROE E1IMINATION S'BTFM (NPDES)
<br />DISCHARGE MONITORING REPORT DMRI
<br />7-18/ 17-191
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<br />PERMIT NUMBER DISCHMOE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAY
<br />FROM Y TO 'r'1 _. !
<br />v6]n rn-av v4751 nb]71 nea.91 !36311
<br />Form Approved. ~ •~
<br />' , ,. ~' I OMBINo. 2040-0004
<br />( .i .1 .3 , ~) Approval ejcgiree OS-31-98~
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<br />NOTE: Reed IrotruelltNr More eompletln8 thre form.
<br />PARAMETER !3 Grd Ontyl QUANTITY OR LOADING ~ I4 Grd On1yl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
<br /> 146531 /5481/ 138-45 !4653 154511 EX OF TYPE
<br />197-37/ ANUrsIs
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rsz-eel r64-5a1 159-701
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<br />NAME/TITLE PRINCIPAL EXECVTNE OFFICER I CEIITIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXMIINEQ ANp
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN
<br />AND BASED ON r ~
<br />~ TELEPHONE DATE
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<br />MY INQUIRY OF THOSE INDINDUAlS IMMEDIATELY RESPONSIBLE FOR ~
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<br /> OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br /> TRUE, ACCURATE AND COMPLETE. I AM AWARE
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<br />SIONIFCANT PENK7IEB FOR SUBMI7TING FALSE INFORMATION
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<br />THE POSSIBILITY OF RNE AND IMPRI90NMENT. SEE 18 U.S.C. ! 1001 AND ~] IONATURE OF PP
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<br />CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Re/erencs e!/eHechmentr here!
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<br />EPA.Fam 3320.1 10&861 Previous editions may ba used. (REPLACES FDA FORM T~40 WHICH MAY NOT BE U6ED.1 q 0 p p ~ ~ q q 0 Q 1 +.-C ~ 2 3 PAGE L OF
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