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PERMITTEE NAME/ADDRESS (lnclde Fanliry NamdLocnn'on ifDiffermtJ
<br />NAME
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<br />ADDRESS ., ° F 8 A G ~? ~: I i c
<br />FACWTY H1,9o LY ,; ~L'., I: ~'
<br />LOCATION
<br />ATTN: JEFF UI!c ~.d:
<br />NATIONAL POLLIfrANr DISCHAgGE ELIMINATION SYSTEM (NPDESJ
<br />DISCHARGE MONITORING REPORT (OMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM D '; S ~~ ~ TO t~ ;
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />' ~ NOTE: Read Instrucllons befoPe'Cl~pleting this form.
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICeray under panalry of law that this document antl all attachments were TELEPHONE DATE
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<br />e. SIGNATURE OF PRINCIPAL EXECUTIVE / (7 / 7 ~v G 2
<br />TYPED O RINTED I em aware that there are signierarrt penalties for submitting hake inbrmallon,
<br />lnclutlin the ssibili of lne antl im risonment br krwwin violations. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />PA orm ~i "( 3140` Pr vfbus`e iti rlsay be used. THIS IS A 4-PART FORM PAGE OF
<br />00475/G0G717-1350 1
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