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PERMITTEE NAME/ADDRESS p~•11de Faciliry Name/Locadon ifDiBerenl)
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<br />NATONAL POLLIfTANT DISCHARGE ELIMINATION SYSTEM (NPDES) FORn Approved.
<br />DISCHARGE MONITORING REPORT (DMRI OMB No. 2040-0004
<br />rz-1s) l1r- 91 ' " T "' ^ Approval expires 05-31-98
<br />~7?7711 )~ nrll ~ /-rno n ~~
<br />PERMIT NUMBER DISCHARGE NUMBER r _ 9 . •. ~ T ~• ~ ~' " '
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<br />MONITORING PERIOD - '
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ''' `li i TO 1 t ._ ._,. L.i ..-.~r:r§n.(r 1_i ;•,.,..
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<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) GUANTITY OR CONCENTRATION NO. FflEOUENC SAMPLE
<br />PARAMETER (46-53 54-51) 38<5) (4G53 (54-61) EX OF TYPE
<br />~~~ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />(6x531 'Wa-~~
<br />(84-68
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<br />NAME/TITLE PRINCIPAL E%ECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />INFORM LAW THAT I HAVE PERSONALLY EXAMINED ANDJ
<br />BMITTED HEREIN
<br />AND BASED ON MV
<br />ATI TELEPHONE DATE
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<br />ON SU
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<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
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<br />__ PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLU
<br />NG THE
<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. § 7001 AND 33 U.S.C.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED § 1319. (Pormltlav antler Nase smaaes may inclutle Nnas up ro 570,000 antl a
<br />maximum lmpnsonment of beMeenBmonOts entl5 years.) OFFICER OR AUTHORIZED AGENT
<br />p
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIULAI IONS (He/erenCe ell eaacnmenrs Were)
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<br />EPA Form 3320-1 (08.95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NO7 BE USED.) O ,7 T , 7 / 7 7 ~ r~ , ~ _ 1 5.7 II PAGE ~ OF
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