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PERMITTEE NAME/ADDRESS B,.>r./. FxmryNrr/laanm d0~,.ev/
<br />NAME _YPi'tt ~~. ~ -.:yr '7>D•
<br />ADDRESS 'INh`, :r )r 7 - ~. `~r '~ ,,,'f„P,A'r VS
<br />9100 ~ ', ,• ~.T _.~?, ^ii'::LS
<br />~A;Lt.:i"D ^_~ 90155
<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCNMOE ELIMINATION SYSTEM INPDESI
<br />DISCHARGE MONITORING REPORT IOMR)
<br />11-761 /I7-191
<br />C000771iU 'ITS ~
<br />PERMIT NUMBER DISCMMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~-~ TO "° ~~ '~
<br />!7677/ /11-131 171-75/ /7817/ 178-191 /3037/
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<br />Form Approved.
<br />m 101,-No. 2040-0004
<br />Approvd expispe OS-31-98
<br />NOTE: Reed Inetructlane before completing Mie form.
<br />PARAMETER 13 Grd Onlyl QUANTITY OR LOADING !I Grd Onlyl QUANTITY OR CONCENTRATION NQ FREOUENCV SAMPLE
<br /> /46531 (5LB7 l38J51 148531 (54-611 EX DF
<br />131-371
<br />MALrSIs TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 1sT-e]! /84E81 (69-701
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<br /> SAMPLE
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTI FY UNpER PENALTY OF UW THAT I HAVE PERSONALLY EXAMINED MD TELEPHONE DATE
<br /> AM FA MILIM WITH THE INFO RMATION SUBMITTED HEREIN; MD BASED ON
<br />
<br />:iicF:ard h1111s MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOP
<br />OBTNNINO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />
<br />Environmental i ~ItdrtGE
<br />f3r TRUE. ACCUMTE MD COMPLETE. I AM AWME THAT THERE ME
<br />SIGNIRCANi PENALTIES FOR 9UBMITTINO FN SE 1NFOIFMATION
<br />INCLUDING
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<br />97D-870-2772
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<br />27
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<br />THE POSSIBILITY OF RNE AND IMPRISONMENT. SEE 18 U.S.C. ! 1001 Mp S]
<br />'
<br />BIONATURE OF PRINDIPAL EXECDTNE J 8
<br /> U.S.C. F 1 ]t e. Fh;r
<br />ni. wtlr rMw mr,rf.. m.y NcAW rxwa vP ro F 10,000 AREA
<br />TYPED OR PRINTED Worm.rirwn lrryASmr+rW Mrwwn sncners rN6YAnal OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV
<br />COMMENTS AND.EXPLANATION OF ANY VIOLATIONS (Rslersnce el/attsehmenb here)
<br />rTLEAyLC i71.T77 'T`I" I id77:.. (L0~ F?F) T^ >L"-rc n mac:.+T ,1.:... - n. ~ 5..
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<br />EPA Form 3320.1 108.951 Prevloue edltlone may be used. (REPLACES EPA FORM 7.40 WHICH MAY NOT BE USED.) ,~„ ~ _ ~ /., - ,,,~ +- 1 r ., .. PAGE , OF
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