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PERMffTEE NAMEIADDRESS QneGde Facility NamdLofnlion 7Differan4 NATIONAL POLLUTANT DISCHARGE ELIMINATION 6YSTFlA (NPDES) Form Approved.
<br />NAME DISCNARGE MONITORING REPORT (OMR1 OMB No. 2040-0004
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<br />F! C K f a Y 2 F i E F C C} _° . 15 !: , L L C m+e) (n-fs/ : t C
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<br />Approval e>gTires 0531-98
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<br />1 3 1 1 8 F E A T R 0 0 0 C F I Y E PERMIT NUMBER DISCHMGE NUMBER E- F I~ J I 1 F t A'
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<br /> (3 Card Ony) QUANTITY OR LOADING Ony1 QUANTITY OR C ~ ENTRA710N NO. F9EOUfN SAMPLE
<br /> PARAMETER (46.53 (50-61 (39-45 4653) 5¢81 Q( OF TYPE
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E7(AMINED AND
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<br />AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDNIDUAL
<br />THE INFORMATION
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<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE
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<br />I AM AWARE THAT THERE ARE SIGNIFICANT
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<br /> PENALTIES FOR SUBMIRING
<br />rT R 4 P POSSIBILrtY OF FINE AND IMPRI
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<br />d FALSE INFORMATION, INCWDING THE
<br />SONMENT. SEE 18 U.S.C. § 1001 AND 33 U.S.C.
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<br />COMMENTS AND IXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here)
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