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PERMITTEE NAME/ADORE66 pweYri frWry Na,Wloc+rlm /D <br />~ NATIONAL -OLIUTANT DISCHMOE ELIMINATON eY6REM NPOES/ <br />D16CHAROE M <br />NIT <br />N <br />~ Form Approved. <br />NAME <br />: I ; + <br />~' • - ~ C~ W ; O <br />ORI <br />G REPORT IO <br />RI <br />y C <br />?-/6 17-19 r, v ~ c F• . <br />it 5 . A 4 4 P', r' ^ <br />OMB No[12040-0004 p v <br />ADDRE66 ;~'a -LX •I"F C'f'0707'10 f, OOP ~ (•"-.r rao ~;v) APProvel~exglee~05-31.98 <br /> 4 6 4 3 $. V I S~ e/ <br />~ <br />r ~ 1 ]'!O PERMIT NUMBER DIBCHMOE NUMBER v /` T ~} A~ I <br />,~~ ; ~¢..vGr <br />f ~ •rl-9rtT ${v 2 3 ~ , • n 7~ • <br />FACaITV r <br />. _.... <br />- MONITORING PERIOD <br />" ~~ YEAR M DAV YEAR MO DAY <br />IOCAT10N1:. .1 r:. ! a <br />J? FROM 9' 7 <br />4 <br />O • <br />` I .y .. r <br />, <br />.; r,: <br />.rv <br />~ ~ r::ia <br />; ') <br />~;~. (.w r 1 <br />[ . ~ <br />7 <br />L T j .l <br />. <br />q <br />. ~ <br />! '" -^ v • .ilT"'-t.: ~'~TK•r- ' : ° ~ P. 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[J r,=p sr.n,; - <br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENN.IY OF LAW THAT I HAVE PEr150NALLY E%AMI <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN: AND BA NFD AND <br />SED ON TELEPHONE DATE <br />( .:V <br />~ r MY INQUIRY OF THOSE INDINDUALS IMMEDUTKV RESPONSIBLE FOfl <br />~ <br />~ <br />l OBTNNING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION 19 I <br />( <br />~ ~ \ <br />~ <br />~~ <br />( <br />~ <br />, ~ ~ ~ /~` [_ ~, r i <br />e SMGNIFLANT MENAL ~S FOR SUBMITTING FALSE INFORMATON NCWDNG ~ <br />[f <br />~ 7i~ ~ <br />~ 7 <br />RU y~ <br />~ <br />] <br />• <br />7 THE POSSIBNTY OF RNE AND IMFRISONMENT <br />SEE IB U <br />S <br />C <br />E 1001 AND 39 1 r L • ~ Q 1 ~ V <br /> . <br />. <br />. <br />. ~IONATURE OF PIIINCIPAL EXECUUVE '~ ' <br />TYPED OR PRINTED U.9.C. 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